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♦UNITED STATES OF AMERICA. 



ASIATIC CHOLERA. 



BY 

F. A. BURRALL, M.D. 



M Glean and gather amoDg the reapers." 



NEW YORK : 

WILLIAM WOOD & CO., 61 WALKER STREET. 
1866. 






Entered according to Act of Congress, in the year 1866, by 

WILLIAM WOOD & CO., 

la the Clerk's Office of the District Court of the United States for the 

Southern District of New York. 



The New York Printing Company, 

SI, 83, and 85 Centre St. 



INTRODUCTION. 



The object of this work is to bring together in a con- 
densed form the more prominent views, especially of 
recent authorities, with regard to this fearfully inter- 
esting disease. It is mainly a study of evidence, in 
which the subject has been considered from many sides, 
and the result is set down in language as far as possi- 
ble expressive of the amount of credence to which the 
different points are entitled. 

The communicability of the disease has been dwelt 
upon at some length, for the adoption of this view is 
of extreme practical importance ; and it is not a suffi- 
cient reply to those facts which are brought forward 
to prove that cholera is communicable, that in ano- 
ther set of cases, and under circumstances apparently 
similar, the disease did not extend. It devolves upon 
those who are unwilling to admit that cholera is trans- 
missible from the sick to the well, to show that the 
facts in favor of such transmissibility are insufficient 
evidence. The testimony of the five witnesses who 
saw the culprit steal the axe, was not weakened by 
that of the twenty who swore that they did not see 
the theft. Enough evidence is on record to warrant 
the assertion, that the connexion between the arrival, 
from an infected to a healthy and sometimes isolated 
locality, of those sick with cholera, and the speedy 
appearance of the disease in that locality, is suf- 
ficiently immediate to stand in the relation of cause 



IV INTRODUCTION. 

and effect. It is also significant that in some cases, 
as in the ship New York, where it was supposed that 
no connexion existed with an infected locality, a 
closer examination has demonstrated that such a con- 
nexion did exist, so clear as not to admit of a rea- 
sonable doubt. 

If a ship laden with poisonous serpents should 
stop on its passage at different ports, where no such 
reptiles existed, and soon after its arrival these veno- 
mous creatures should be observed in those ports, the 
natural inference would be that they had been 
brought thither by that ship ; and it would not be a 
sufficient reason for disbelieving it, that in some other 
ports touched by the same vessel, no such reptiles had 
subsequently made their appearance. 

Something has been learned of the characteristics 
of this pestilence, although very much still remains 
in obscurity. 

It may be claimed as known, that in the large 
majority of cases the disease is preceded by a pre- 
monitory stage which is easily controllable ; that 
instead of sweeping with the wind over oceans and 
continents, there is ample reason to believe that 
human intercourse is the means by which it is pro- 
pagated, and that the noxious element requires cer- 
tain foul adjuvants for prolific germination. Accu- 
mulating evidence goes to prove that a kind Provi- 
dence has placed even this great scourge among the 
number of preventable diseases. 



Page 46 — Atlantic should read A talari ta. 
Page T5— 1855 should read 1865. 



ASIATIC CHOLERA. 



CHAPTER I. 



The successive epidemics of Asiatic Cholera which have 
prevailed since 1817, when it first left the Delta of the 
Ganges to become a universal pestilence, have been marked 
by a striking uniformity in their prominent features. In 
fact, this uniformity excites a doubt as to whether the 
destructive epidemics of cholera, which reliable authorities* 
have described as existing previously to 1817, could have 
committed such fierce ravages and yet remain within such 
comparatively narrow limits, if there had been present the 
same progressive elements which have characterized its sub- 
sequent career. It is also remarkable that medical writers 
of remote antiquity, in describing the cholera as a disease 

* Aretseus (A.D. 50) gives an account of cholera, and describes 
the dejections, loss of voice, general coldness, and suppression of 
uriue. The disease is also noticed in Sanskrit. From 1^69 to 1190 
there are also reliable accounts of cholera (endemic?) by Chisholm, 
Folly, Curtis, Girdlestone, Jameson, Johnson, Konig, Sonnerat, Thom- 
son, and others. See ''Die Epidemische Cholera. 7 ' Dr. Drasche, 
Vienna, 1860. 



ASIATIC CHOLERA. 



indigenous to the banks of the Ganges and detailing its 
features, do not speak of its epidemic character ; for this is 
noticed by them as a mark of other pestilential diseases of 
that period, and is so striking a feature of Asiatic Cholera 
that it could not have escaped observation if it had been 
present. The probable inference therefore is, that the cases 
described were for the most part instances of sporadic cho- 
lera, while it is possible that other diseases with somewhat 
similar symptoms were also described under that name. 

From the middle of the eighteenth century to its close, 
and during the early part of the nineteenth,* there are trust- 
worthy accounts of violent epidemics, yet the disease still 
remained within its original limits. It is true that epi- 
demics which resembled the Cholera of India prevailed 
during portions of that period in Madras and Mauritius, also 
in Pennsylvania (Will. Curie, Philadelphia, 1790) and the 
Antilles; but it was not until 1817 that the disease dis- 
played those characteristics which have secured for it such 
a dreadful prominence as the Epidemic Cholera. 

It will be interesting to notice the circumstances under 
which the cholera assumed in 1817 such striking epidemic 
features, while it may also throw some light upon the nature 
of the disease. 

In the report of Dr. James Jameson,f it is stated that 

* Trincomali, 1804; 1814, among the troops at Jaulnah; 1816, in 
the district of Purneah. 

f Eeport on the Epidemic Cholera Morbus as it visited the terri- 
tories subject to the Presidency of Bengal in the years 181Y, 1818, 



ASIATIC CHOLERA. 7 

unusual variations from the ordinary course of the weather 
were observed in Bengal in February, 1817. This month 
was more like an autumn one, with rain every third or 
fourth day. In March there were frequent alternations of 
clear and cloudy weather with very severe storms. April 
was more regular, but the rain appeared in May fifteen or 
twenty days earlier than usual, and then diseases of the 
bowels made their appearance. June and July were unu- 
sually rainy, and there was also much rain in the beginning 
of August, but in the middle of the month the heat was 
extreme. Ordinarily the air becomes cooler and more 
refreshing during the rainy months ; but in 1817 the exces- 
sive heat destroyed this beneficial influence. The end of 
August was accompanied with constant rain, by which the 
air became suddenly cooled. As a result, while the cases 
of fever which occurred were mild, there followed severe 
attacks of diarrhoea and inflammation of the liver, and now 
cholera made its appearance in a most active form. 

The disease had already prevailed during May, June, and 
July, in Nuddya and Mymunsing, districts far distant from 
each other, but as it was limited to distinct localities and 
not often fatal,* no special notice was taken of it until the 
middle of August, when its virulence and rapid spread 
caused universal alarm. 

and 1819, etc., by James Jameson, Assistant Surgeon and Secretary 
of the Board. Calcutta, 1820. 

* Ueber den Ursprung und die Verhutung der Senchen, &c, von 
Dr. W. F. P. Kiehl, etc., etc. Berlin, 1865. 



8 ASIATIC CHOLERA. 

It was at this time that Jessore was visited by the dis- 
ease, and it is a prevalent belief that during this visitation 
the cholera underwent certain changes, which so modified 
its character that it became in many respects a new disease, 
and hence the origin of epidemic cholera has been placed 
in that town. Previous to the attack upon Jessore the 
malady had (with the exception of occasional severe local 
epidemics) prevailed at certain seasons in several places 
simultaneously, as a disease indigenous to India, apparently 
produced by atmospheric or malarial causes. It had at- 
tacked chiefly the natives, was not greatly feared by foreign 
residents,* and subsided as the cooler weather came on. 
But after having appeared as an epidemic in Jessore, it 
assumed a wandering character, and, as if humanized, passed 
along the great highways ; stopped at some houses or vil- 
lages, while capriciously neglecting others ; entered ships, 
and was carried through rivers and across seas, and followed 
man all over the world. 

Jessore,f a thickly populated town, one hundred miles 
north-east of Calcutta, is situated in the midst of the Delta 
of the Ganges, on a flat, reedy bank of the river, slightly 
elevated above sea-level, on a soil composed of river de- 

* Kiehl. "Ueber den Ursprung," &c. 

t It was so rare among foreign residents that neither of the phy- 
sicians who had been connected, one for five, and the other for ten, 
years, with the General Hospital of the Bengal Presidency for Eu- 
ropeans, had seen a single case of the disease previously to the out- 
break of the epidemic. 



ASIATIC CHOLERA. 9 

posits, placed in beds of clay and sand. During August 
there is little variation in the climate of that vicinity, it 
having a medium temperature of 81° Fahr., which is the 
same as that of the river surface. The barometer has a 
medium height of 29.45. " About eighty miles distant is 
the tract of Soonderbunds,* and the hot south-west monsoon 
scatters pestilential vapors over all parts of the Delta for 
six months of the year. From the 15th July until 15th 
October, the atmosphere in Bengal possesses all the pro- 
perties of a filthy vapor bath, producing a sensation of in- 
describable fatigue and oppression, and an exhausting per- 
spiration.'^ On the north side of Jessore a shallow, almost 
stagnant, arm of the river extends inwards, having an ori- 
ginal bed about seventy-five yards wide. During the rainy 
season this bed was transformed into a fetid swamp, cover- 
ed with rank vegetation. By the side of this sluggish wa- 
ter stood the bazaar, and long narrow rows of low, mean 
huts, surrounded by trees, which afforded shade, but pre- 
vented the rapid escape of moisture. The stream was the 
receptacle for excrementitious matters, and the bodies of 
partly burned corpses were also thrown into it, in accord- 
ance with religious superstition. The water of this stream 
was also used to some extent for drinking purposes.^ 

* This is the name given to a large number of low and marshy 
islands in the Delta, formed by the different channels which the 
Ganges makes in its course to the ocean. 

f Kiehl. 

X An estimate has been made that the Granges empties 550.000 
cubic feet of sediment every second into the ocean. 



10 ASIATIC CHOLERA. 

In addition to these extremely insalubrious conditions, 
the rice crop, which furnished the chief subsistence of the 
natives, had turned out badly in 1817. " Eice is, in conse- 
quence of the large proportion of starch and gum which it 
contains, a good vegetable aliment, but when employed as 
the sole article of diet, insufficient for the wants of the sys- 
tem. But the blood of the individual depends upon the 
nature of the food consumed, and therefore the blood of 
the Bengalese must be of a poor quality, deficient in albu- 
men and fibrin."* 

According to an analysis made by J. Moleschott, rice 
contains, on an average, in 1000 parts : 

Gum and Soluble Albumen 50.69 

Cellulose 10.18 

Starch 822.96 

Dextrin 9.84 

Sugar 1.73 

Oil 7.55 

Salts 5.01 

Potash 1.01 

Soda 0.13 

Lime 0.35 

Magnesia 0.21 

Oxide of Iron 0.12 

Phosphates 3.12 

Silicates 0.07 

Water 92,04 

There are two rice harvests yearly in India. The cho- 

* Kiehl. 



ASIATIC CHOLERA. 11 

lera of 1817 occurred about the time of the first harvest, in 
the rainy season, in August. This first rice is very un- 
wholesome, and the natives consume a third less of it than 
of the older quality. Sometimes it even produces a fatal 
disease characterized by vomiting and diarrhoea.* Such 
food as this would increase any intestinal irritability in a 
marked degree. 

The first cases of cholera noticed in Jessore were in the 
narrow streets near the swamp, during the rainy season. 

On the 19th August, 1817, Dr. Tytler, the physician of 
the English colony in that city, was called at mid-day by 
a native physician, to see a middle-aged man who was sick 
in the bazaar. At first, Dr. Tytler supposed the case to 
be one of narcotic poisoning, and this suspicion was in- 
creased by the fact that the man was to appear as an im- 
portant witness in a criminal case. The sickness proved 
fatal on the following day, and then it was discovered that 
ten others had died with similar symptoms in the same 
corner of the bazaar, and more lay sick with the disease in 
other parts of the city. 

Now, it does not seem possible that this could have 
resembled even a severe attack of the ordinary cholera of 
India ; for Dr. Tytler, who was an intelligent man, and must 
have seen that disease, considered that this patient was suf- 
fering from a specific malady caused by the use of noxious 
rice.f 

* Kiehl. 

I Remarks upon Morbus Oryzaeus ; or, Disease occasioned by the 



12 ABIATIO CHOLERA. 

On the other hand, investigations made after the out- 
break of the disease in Jessore, showed that cholera had 
been prevailing as an epidemic along the Ganges from 
May until August, and the opinion is quite general that the 
disease which attacked Jessore was, in its commencement 
there,, an extension of the epidemic. It is also noticeable 
that physicians of India who had seen the cholera epide- 
mics of the eighteenth century, and who now saw this later 
pestilence, considered them as identical diseases. Hence, 
there is good reason to regard Asiatic cholera not merely 
as sporadic cholera prevailing epidemically, but as the ende- 
mic disease so metamorphosed by some specific influence 
or agent as to have become what, in the absence of an inti- 
mate knowledge of the disease, is termed malignant.* 
Something similar to this is noticed in the difference be- 
tween the simple and malignant forms of the exanthemata, 
and in those throat diseases which assume a grave diphthe- 
ritic character. 

Why epidemics should be more severe at some periods 
than at others is a matter of speculation ; yet this is a fea- 
ture connected with the outbreak of cholera in 181 7 and of 
subsequent extensive visitations of the disease. They have 
been preceded by unusual activity of the malady in Hin- 
dostan. This was the case with those of 1831 and 1832, 

Employment of Noxious Eice as Food. In Two Parts. By Robert 
Tytler. Calcutta, 1820. 

* This term is used to express the effect of certain causes not yet 
understood. 



ASIATIC CHOLERA. 13 

and in 1860 the epidemic prevailed extensively in the valley 
of the Ganges between Calcutta and Putna. In 1861 the 
most serious epidemic since 1846 broke out in and extended 
over the north-west provinces of India. While pursuing 
this course it appeared in Candahar and Bagdad, on the 
western and thrice followed track. In 1863 the mortality 
of the disease in Bombay was fifty per cent, above the ave- 
rage ; and in March, 1865, the cholera showed itself on 
the banks of the Ganges, and prevailed as an epidemic for 
twenty-two days without leaving the country. 

A review of the circumstances connected with the out- 
break of epidemic cholera presents the following facts. A 
season of unusual atmospheric changes was accompanied by 
an earlier and more general visitation of endemic cholera. 
The fatality was not very marked until August, when, per- 
haps rendered more active by the advanced season, it 
visited during the rainy months a locality in the malarious 
Delta of the Ganges, slightly elevated above sea level, having 
a fetid swamp beside it which served as a receptacle for 
excrementitious substances, and the water was also some- 
times used for drinking. The inhabitants, degraded and 
filthy,* were badly nourished or partially poisoned by a 
defective crop of the staple which formed their principal 
subsistence. The streets were narrow and dirty, the huts 
overcrowded, and the air within them poisoned by emana- 
tions resulting from excessive crowding. In short, malaria, 

* Report of College of Physicians of Philadelphia to Board of 
Health. Philadelphia, 1832. 

9* 



14 ASIATIC CHOLERA. 

defective nourishment, and animal filth, stand forth promi- 
nently in connexion with the outbreak of the cholera in 
Jessore. 

Such circumstances would be likely to produce disease, 
or to modify it when originated. The instances are very 
common in which a low state of the system will render a 
mild disease severe, and transform even a simple incision 
into a gangrenous ulcer. Even vaccination, under similar 
conditions, is followed by very severe inflammation, while 
the influence of filth and crowding, in giving increased viru- 
lence to disease, is generally admitted. Martin notices the 
effect of these causes, and says : " It was amongst the poor, 
ill-fed, ill-clothed, and crowded inhabitants of Jessore that 
epidemic cholera made its first appearance." 

In this connexion may be noticed the early cessation of 
a severe cholera epidemic, which is narrated by Kiehi to 
show the effect of favorable hygienic conditions in arresting 
disease. 

In 1783 more than a million of pilgrims came to Hur- 
divar in India, during the time of the April full moon, to 
bathe in the sacred waters of the Ganges. It was their cus- 
tom to pass the night near the river with scarce a roof to 
cover them, or under the open sky. The climate of this 
vicinity is very changeable ; hot, sultry days, alternated 
with cold nights and heavy dews, while the proximity of high 
mountains rendered it liable to sudden blasts of cold moun- 
tain air. The cholera broke out soon after the commence- 
ment of the ceremonies and destroyed over twenty thousand 



ASIATIC CHOLERA. 15 

souls. Yet the town of Juvalapore, ©nly seven miles dis- 
tant, was not affected by the disease, and the pestilence 
ceased when the pilgrims separated. 

The chief reasons assigned for the cessation of this epi- 
demic are, firstly : That the causes which occasioned it 
were of a passing or temporary character ; that is, it ori- 
ginated among a transitory population. Secondly : Hurdi- 
var was about seven hundred miles from the mouth of the 
Ganges, and nine hundred and fifty feet above sea level. 
Besides, the pilgrims were not in houses, but encamped in 
the open air, and the disease appeared early in the season, 
before the protracted summer heat. 

Some have considered the different varieties of cholera 
(cholera morbus, sporadic cholera, endemic cholera, cholera 
Asiatica) to be varying grades of the same morbid process, 
depending upon differences in climate and surroundings for 
the variations in intensity. There is a similarity in the 
symptoms of each, so great, occasionally, as to cause per- 
plexity in diagnosis, and the post-mortem appearances of 
sporadic cholera have sufficiently resembled those found in 
Asiatic cholera to lead some authorities (Andral, Brown, 
Ferrus, Griesinger*) to regard them as essentially similar. 
With regard to the distinction drawn between sporadic and 
epidemic cholera, from the absence of bile in the dejections 
of Asiatic cholera, Memeyer says : " It must not be inferred 
from the paleness of the dejections, that the formation or 

* Die Epidemische Cholera, von Dr. Drasche. Vienna, 1860. 
Page 308. 



16 ASIATIC CHOLERA. 

excretion of bile has ceased ; for even if the bile were pro- 
duced in normal quantity and poured into the intestine, it 
could not exert any marked effect upon the coloration of 
such a large quantity of fluid." 

Yet, as has been previously said, there is good reason to 
believe that epidemic cholera is something more than an 
aggravated form of the endemic variety, but the relations 
which they bear to each other are at present a matter of 
opinion on which high authorities differ, and which still 
waits for a satisfactory solution. 

There have also been decided differences in the views 
taken by able observers, concerning the nature of the ulti- 
mate cause of epidemic cholera. Even as early as after the 
first general invasion of cholera, the theory was advanced 
that the ultimate cause of the disease was of an animal na- 
ture. An infusorial contagion, originating in the swampy 
districts of Hindostan, while plausible, is thought to ex- 
plain some of the strong peculiarities of the disease. The 
almost marvellous vitality of microscopic animalcules, as 
well as of their germs, is supposed to account for the pe- 
riodic renewals of the disease at comparatively short inter- 
vals—latent germs being quickened — either as the result of 
fortuitous circumstances, or in consequence of peculiar in- 
herent laws.* The extinction of epidemics also has its 

* A distinguished lady of title has lately made a communication to 
the French Academy of Sciences, in which she declares that she has 
discovered the cause of cholera in a microscopic insect which she 
calls the " winged leech," and which, she says, is developed espe- 



ASIATIC CHOLERA. 17 

analogue in the entire extermination of myriad swarms of 
insects; but a thorough examination of the infusorial 
world during cholera epidemics has given no positive re- 
sults, so that the question still remains unanswered. The 
same may he said with regard to the theory that the cho- 
lera contagion is of a vegetable nature ; a fungoid growth de- 
veloping in the cholera dejections. Pettenkofer's opinion 
is very decided upon this point, and is thus expressed, in a 
recent journal : " Without the least danger of making an 
error, we can assert that the substance in question (the ulti- 
mate cause of cholera), although quite unknown to us as a 
separate entity, must be of organic nature, and either a cell 
or a ferment."* 

The solution of these questions would not only be of the 
greatest importance, as related to cholera, but would, in all 
probability, throw much light upon many obscure points 
in other diseases. 

cially in marshy and filthy localities. The details she gives in rela- 
tion to this animalcule and its connexion with cholera, are so 
minute that the Academy, which commenced by laughing at the first 
paragraphs of the report, finished by deciding to investigate the 
matter. — Letter from Paris in New York Times of February bth, 1866. 
The correspondent, "Malakoff," is an American physician, living in 
Paris. 

* Beilage zur Allgemeinen Zeitung, October 9th, 1865. 



18 ASIATIC CHOLERA. 



CHAPTER II. 

The evidence in favor of the contagious nature of cholera 
is, mostly if not altogether, of a circumstantial character. 
While the disease is not contagious in the same manner as 
small-pox and scarlatina, yet the well authenticated cases 
are so numerous, in which a direct connexion has been 
traced between the origin of a cholera epidemic, and the 
arrival of an individual from an infected to a previously 
healthy neighborhood, that there should be no doubt as to 
the spread of the disease by human intercourse. This 
point may be considered as so well established that a prac- 
tical disregard of it involves the assumption of a grave 
responsibility. 

The evidence which is advanced against the contagious- 
ness of cholera does not weaken the accumulated force of the 
facts in its favor, some of which do not admit of a reasonable 
doubt, but it only shows that the liability to contagion is 
diminished, or strengthened, by certain localizing causes. 

Preconceived opinions, although honestly taken, have 
been in many instances an obstacle to the belief in the com- 
municability of cholera from individual to individual, and 
the same result has been produced in others from a failure 
to appreciate the indirect manner in which the disease is 
believed, on good evidence, to be communicated. 

The other methods supposed to account for the exten- 



ASIATIC CHOLERA. 19 

sion of cholera are, in general terms : — Progressive atmo- 
spheric influence, local atmospheric influence, and terrestrial 
emanations.* It has been found, however, that as diffusive 
agents they are insufficient to explain the peculiar features 
and progress of the malady. 

The following opinions, from a distinguished authority, 
upon certain atmospheric conditions supposed to favor 
cholera epidemics, are the results of extensive experience, 
and are entitled to very great respect : 

" Great importance has been attached to the meteorolo- 
gical conditions attending an outbreak of cholera ; they do 
not appear to be very important except in two or three cases. 

" 1. Temperature. — High temperature favors spread by 
increasing the putrefaction of the stools, and by augmenting 
generally the impurity of the air. When cholera has pre- 
vailed at a low temperature (it has been severe at a tem- 
perature below freezing), the drinking water has possibly 
been the cause. 

" 2. Pressure. — Pressure has no effect. The old observa- 
tion of Prout, that the air is heavier in cholera epidemics, 
has never been confirmed. 

" 3. Moisture in Air. — Combined with heat, this seems an 
accessory cause of importance, probably by aiding trans- 
mission. 

" 4. Dryness of Air. — Seems decidedly to check it. 

" 5. Rain. — Sometimes augments, sometimes checks, it. 

* Byrne on Cholera, page 28. Philadelphia, 1854. 



20 ASIATIC CHOLERA. 

This, perhaps, depends on the amount of rain. A very 
heavy rain is a great purifier. 

" 6. Movement of Air. — It is certainly worse in stagnant 
atmospheres, as in the cases of all the specific poisons. 

" 7. Electricity. — Is not known to have any effect. This 
was particularly examined by M. Lamont, in Munich, one 
of the most celebrated physical philosophers of our time, 
but with entirely negative results. 

" 8. Ozone — Has no effect on its presence or absence 
(Schultze, Voltolini, Du Methe, Lamont)." 

The history of cholera shows that its usual method of 
progress is from a centre * in more or less irregular direc- 
tions ; yet, at the same time, its course has been more 
strongly imprinted along the chief lines of trade and inter- 
communication.! The grand routes of travel and traffic have 
always been especially marked in its progress ; it has follow- 
ed large bodies of men in motion ; and when it has passed from 
one continent to another, the first cases have been observed 
in seaport towns, from which it has spread to the interior. 

" Cholera has frequently attached itself to bodies of 
troops on their march in India, and has remained with 

* Reports on Epidemic Cholera, etc., by William Baly, M.D., and 
William W. Gkill, M.D. Lond. 1854, p. 96. 

f " Hastened down the Ohio and Mississippi rivers to New Orleans 
with the rapidity of a steamboat." — Byrne on Cholera. Pettenkofer 
explains the prevalence of cholera near rivers by the presence of 
moisture held by the soil (grundwasser), which he regards as a chief 
localizing cause. 



ASIATIC CHOLERA. 21 

tliem during many days in their passage over long tracts 
of country, the inhabitants of which were not suffering 
from the epidemic. The duration of the epidemic in 
marching regiments is stated by Dr. Lorimer, who has col- 
lected the largest number of instances, to be, in the ma- 
jority of cases (in 88 out of 121), less than thirty days. 
It has often, however, been longer, and in the more severe 
outbreaks, the epidemic reached its climax in the regiment 
about the eighteenth day. Many points relating to these 
attacks of marching troops in India are matter of dispute, 
but the fact that the disease remained with them for many 
days, when it did not prevail in the country round, seems 
not to be gainsaid: and here, again, the inference is irre- 
sistible that the cause of the disease travelled with the 
troops, and affected different men in succession."* 

Byrne notices the singular circumstance that, although at 
the date of his writing (1854), thirty-four years since the 
cholera first reached Canton, it had never crossed the atmo- 
sphere of the Pacific ; yet since immigration to America had 
become very extensive it had crossed the Atlantic a number 
of times. 

Besides, it cannot be regarded as a mere coincidence that 
the disease should never have been seen on the coast of 
South Carolina before the arrival of the brig Amelia in Oc- 
tober, 1832, at Folly Island ; and that the only cases on the 
island were of those employed about the vessel ; or that the 
first cases at Detroit occurred soon after the arrival of the 
* Baly and Glull, page 135. 



22 ASIATIC CHOLERA. 

Henry Clay, July, 1832, with cholera on board ; or that it 
never should have appeared at Key West until the arrival 
of the Ajax, which had sailed from the infected port of New 
Orleans, and which arrived at Key West with the disease on 
board ; besides many other well authenticated instances of 
a similar character. 

The present epidemic is consistent with previous ones in 
affording evidence that the disease has been mainly diffused 
along the lines of travel by means of human intercourse.* 

Dr. Tilbury Fox, who was travelling in Syria at the time 
when the epidemic prevailed there, states, that numbers of 

* Dr. Althaus in a letter to the Medical Times and Gazette, dated 
October 30th, 1865, writes the following with regard to the recent 
introduction of cholera into Saxony: "In Berlin, Yienna, and other 
large towns no case of cholera has as yet occurred. But the disease 
has been imported into the very heart of Saxony by a few travellers 
who left Odessa some weeks ago when cholera was at its height 
there. These gentlemen, a few days after, having arrived at Alten- 
burg, a small town near Leipzig, fell ill and died with all the symp- 
toms of cholera. Several of the inhabitants of Altenburg were subse- 
quently affected and died, and the disease then spread to "Werden, 
a neighboring town which is in railway communication with Alten- 
burg, and where the epidemic has assumed comparatively large 
dimensions. Up to October 20th there had been 149 cases of cho- 
lera at Werden, of which 52 proved fatal ; and according to the latest 
accounts the epidemic is by no means decreasing. This insulated 
outbreak of cholera in a previously healthy country, and which is 
clearly traced to persons coming from a centre of infection, must 
prove an important link in the evidence already accumulated to prove 
the contagious nature of the disease." 



ASIATIC CHOLERA. 23 

pilgrims from Southern India died of cholera during the 
months of February and March, at the Arabian ports of 
Djeddah and Moculla, Eighty deaths occurred on one 
vessel which arrived off Moculla in mid-winter, before the 
companions of those who had died left the ship for Mecca. 
Egyptian physicians have also established the fact beyond 
question, that the disease advanced in the last weeks of 
May from Arabia along the North African coast, and Egypt 
was soon visited by the pestilence conveyed thither by the 
flying pilgrims.* In the report of the chief physician at 
the Isthmus, it is stated that nearly 20,000 pilgrims, all more 
or less infected, passed Suez in order to embark at Alex- 
andria for Europe or elsewhere. Suez, Alexandria, and 
Marseilles were healthy until some pilgrims from Mecca, 
who had embarked at Djeddah, where the cholera prevailed, 
arrived at those ports. 

Prof. Tommasini, who published a work on cholera in 
1837, states, on the authority of Dr. Frias, a physician of 
Leghorn, who had lived several years in Alexandria, that 
the disease was originally carried from Mecca to Alexandria 
by pilgrims returning from the same feast of Kurban Bai- 
ram.f This year the same carriers seem to have borne it 

* Geographical and Statistical Report of the Epidemic of this Tear. 
Dr. Drasche, Docent. Wiener Med. Wochen-schrift, 1865, No. 66. 
"Intelligence from Bagdad states that cholera appeared among the 
pilgrims from Mecca ; thousands died in a few days." Ibid. 

f Sul Cholera Morbus. Nozioni, etc. Prof. G-. Tommasini, Bo- 
logna, 183*7. 



24 ASIATIC CHOLERA. 

from Mecca in all directions, since it followed the main 
routes of the caravans.* 

Steamships have also played an important part in carrying 
the seeds of the present epidemic to different parts of the 
Mediterranean, Black Sea, and up the Danube. They were 
overcrowded with those flying from the different places 
where the pestilence prevailed ; and outbreaks of the disease 
occurred at various landings soon after the arrival of the 
steamers. It was also noticed that the disease would pass 
by ports nearer those localities where the malady was then 
raging, and attack others more distant, with which the 
means of communication were more frequent and direct. 
Thus it passed by Candia, Rhodes, and the Cyclades, and 
first appeared at Samothraki and Salonica. 

The reason why the disease showed a tendency to prevail 
in the basin of the Mediterranean is, that it was carried to 
the different seaports by the steamers, and spread from those 
ports as centres. On the Black Sea the regular line of 
steamships was discontinued, for it became evident that the 
disease was being propagated by means of them. 

The recent introduction of the disease into Constanti- 
nople, was by a ship which had been lying in the port of 
Alexandria. It is stated f that Osman Pacha came by way 

* The epidemic which broke out in 1848 in Egypt, is traced to a 
festival in Tantah, in honor of a Mohammedan saint, which called 
together about 165,000 pilgrims. The cholera appeared among them, 
and immediately on their dispersion was observed in Alexandria. 

f Dr. Drasche. 



ASIATIC CHOLERA. 25 

of Alexandria in the beginning of July, bearing a message 
to Constantinople concerning the Suez Canal. Three per- 
sons died of cholera on the passage. The physician and 
captain concealed the deaths, at the Pacha's order, and 
declared the ship healthy to avoid quarantine.* The first 
cases treated in the Marine Hospital belonged to the crew, 
and the epidemic commenced in that part of the city near 
the hospital. 

The coincidence of the outbreak of the disease on this 
continent, and on islands in the middle of the ocean, with 
the arrival of an infected ship from an infected port, is one 
of the most conclusive facts in favor of the transmission of 
the disease by human intercourse. There are a number of 
well authenticated instances of this character.f 

The brig Carricks sailed from Dublin, then infected with 
cholera, in April, 1832, having 175 emigrants on board. 
The disease appeared among the passengers a few days after 
leaving port, and forty-two persons died of it before the 3d 
June, when she arrived at Quebec. The remainder were 
permitted to land on Grosse Isle, a few miles from Quebec, 
and no rigid measures were taken to prevent intercourse 

* Here is an instance in which quarantine regulations have been 
inefficient in warding off the disease. 

f Byrne notices the circumstance that cholera follows the line of a 
single vessel when crossing the ocean, but branches out in a hun- 
dred directions after reaching the land. See also London Lancet of 
March, 1854, page 236. Also British and Foreign Med. Chir. 
Review, Oct. 1865. Barraut on Cholera. 



26 ASIATIC CHOLERA. 

between them and the city. Several cases of cholera ap- 
peared in Quebec on the 6th, 7th, and 8th of June, and on 
the 9th, fifteen cases were reported officially. This was the 
beginning of cholera in America. 

The emigrant ship New York sailed from Havre on 9th 
November, 1848, and the epidemic made its appearance on 
the sixteenth day of the voyage. Fourteen fatal cases oc- 
curred during the passage, and on the 2d December, cho- 
lera patients were landed at the Quarantine Hospital on 
Staten Island. Eight cases and five deaths immediately 
occurred on Staten Island, and there was a severe epidemic 
in mid-winter upon the Quarantine grounds. 

At about the same time (11th December, 1848), the 
ship S wanton, also from Havre, reached New Orleans with 
280 emigrants on board. Thirteen passengers had died at 
sea, subsequently to 26th November, most of them from 
bowel complaints, supposed to be dysentery. On the day 
following the arrival of the ship at New Orleans, a woman 
with well marked cholera was taken to the hospital. On 
the following day, a man who had come over in the ship 
and had diarrhoea on his arrival, was brought in a state of 
collapse to the hospital, and died in a few hours. Three 
other cases of cholera, all fatal, were admitted from differ- 
ent parts of the city the same day. In these latter cases, 
no communication with the ship was traced. The disease 
now spread rapidly in the hospital and city, although it did 
not exist at this time in any other part of the United States 
except Staten Island. These cases are not recent, but are 



ASIATIC CHOLERA. 27 

introduced in connexion with the following extract from an 
article in the British and Foreign Medico-Chirurgical Re- 
view* for October, 1865, which refers to the vessels just 
mentioned : 

"It was in the last week in November, 1848, that it 
manifested itself at sea, on board two emigrant vessels, 
bound, the one for New York and the other for New Or- 
leans ; when they had been out, the former sixteen and the 
latter twenty-seven days from Havre, which was unaffected 
at the time of their departure. The circumstances attend- 
ing the nearly simultaneous appearance of the disease in 
two vessels traversing the Atlantic, and about a thousand 
miles apart, are among the most curious on record in the 
history of epidemic cholera. The disease did not extend 
beyond the limits of the Staten Island Hospitals at New 
York, after the arrival of the infected ship there." 

These incidents, apparently obscure, admit of an easy 
solution ; for although the disease may not have existed in 
Havre when the emigrants passed through that city, they 
came from and through cities where the cholera then pre 
vailed. One of the emigrants died of cholera in Greenwich 
street a few days after leaving the " New York," and soon 
after two other fatal cases occurred in the neighborhood. 
There were more than 1000 fatal cases reported from the 
emigrant vessels at Quarantine, and a severe epidemic raged 

* Sketch, of the Geography of Epidemic Cholera, by G-alvin 
Milroy, M.D., F.RC.P. 



28 ASIATIC CHOLERA. 

at the Quarantine grounds during the winter. This is stated 
on excellent authority. 

The circumstances connected with the appearance of the 
cholera on the " Atalanta," which arrived off New York on 
the 2d last November, are so well known that they may be 
passed with the observation, that in this case the disease, 
instead of making a bound from Havre to Staten Island, 
was carried in the ship by emigrants who had come from 
hotels * where the cholera prevailed. It did not extend to 
the first cabin, but remained in the steerage, probably be- 
cause the cabin passengers were not near the dejections, 
and sanitary regulations were carefully enforced among them 
by the surgeon of the ship. 

M. Grimaud f narrates the following facts concerning the 
epidemic in Marseilles. The Stella, Capt. Regnier, entered 
the port Napoleon on Sunday, June 11th, at half-past two 
from Alexandria, with ninety-seven passengers, of whom 
sixty-seven were Algerine pilgrims. On the evening of the 
same day the Byzantine arrived with fifty-five passengers,J 
having left Alexandria June 3d and touched at Malta. The 
Syria arrived on the 15th, with the English mail and 320 
passengers ; and the Said on the 16th with 190 passengers. 
Of the 67 pilgrims on the Stella two were thrown into the 

* Philadelphia Med. and Surg. Reporter, Jan. 13th, 1866. 

f See Boston Med. and Surg. Journal, Jan. 1st, 1866, and Gazette 
des Eopiiaux, Oct. lTth and 26th, 1865. 

% This makes a total of 562 passengers, arrived from Alexandria 
at a time when cholera was in its ascendant there. 



ASIATIC CHOLERA. 29 

sea eight days after leaving Alexandria ; and two days after, 
on the 11th June, the remaining sixty-five disembarked, of 
whom Ben Kaddour died on landing. 

The Arabs left Fort St. Jean to re-embark; a crowd sur- 
rounded them and assisted them with their baggage outside 
the fort. It also accompanied them along the bridge over- 
looking that part of the city. There the first case of cho- 
lera appeared, but it did not remain there, for on the 22d 
June a severe case was reported by Dr. Forcade in Rue de 
Rome ; and thus the cholera was, for the sixth time, intro- 
duced and developed in Marseilles. % 

Dr. Baly,* in his " Report on the Cause and Mode of Dif- 
fusion of Epidemic Cholera," gives some very interesting 
accounts of the disease as it was observed in eighteen lunatic 
asylums in England. This report consists mainly of deduc- 
tions made from the replies of English physicians to ques- 
tions on cholera, which were addressed to them by Drs. Baly 
and Gull in 1848 and 1849, during the prevalence of cholera 
in England ; and its conclusions are of great importance. The 
weight of opinion is increased by the fact, that while in the 
commencement of their investigations these gentlemen were 
disposed to question the contagiousness of cholera, their 
views became much modified as their inquiries progressed. 
The report says : 

" The commencement of the disease usually in one limited 

* Reports of Epidemic Cholera drawn up at the Desire of the Cho- 
lera Committee of the Royal College of Physicians, by William Baly, 

M.D., and William W. Gull, M.D., London, 1854. 

3 



30 ASIATIC CHOLERA. 

part of a public establishment, or in one of a group of 
bouses, and its extension to others in succession, is not 
easily reconcilable with the theory of a general and persist- 
ent state or influence. To adapt this theory to the facts, 
one of two hypotheses must be adopted : either it must be 
assumed that a peculiar condition of localities is necessary 
for enabling the general epidemic influence to produce its 
effects, and that when one part of a public establishment or 
a group of houses previously free from this condition, has 
on a sudden acquired it, other parts are very likely to par- 
ticipate in it, in more or less quick succession ; or else it 
must be supposed that a peculiar state of susceptibility is 
necessary in the persons who are to be affected by the hypo- 
thetical epidemic influence, and that when one or more 
among the inmates of a public establishment or group of 
houses who have all hitherto resisted that influence, chance, 
from whatever cause, to acquire the necessary state of sus- 
ceptibility, those in different parts of the building or in con- 
tiguous houses are apt successively to fall into the same state. 
" A much more probable explanation of the commence- 
ment of the epidemic in one part of an asylum or other 
public establishment, and of its subsequent extension through 
other parts, is obviously afforded by either of the other the- 
ories, which suppose the cause of the disease to be a mate- 
rial poison transferable from spot to spot, and from person 
to person, by human intercourse or currents of air. Again, 
if the theory of the production of cholera by a general atmo- 
spheric influence were adopted, the continuance of the 



ASIATIC CHOLERA. 31 

disease in each ward of a lunatic asylum for a certain time, 
its cessation in some wards sooner than in others, its final 
disappearance from almost all before the epidemic in the 
neighborhood had come to an end, could be explained only 
on the supposition of the temporary existence in each ward 
in turn, of that supposed condition, either of the locality or 
of the patients, which was necessary to excite the general 
atmospheric cause to action. The difficulties in the way of 

this hypothesis are obvious 

" If, on the other hand, the theory of contagion be rejected, 
and the cause of cholera be regarded as a poison not repro- 
duced within the bodies of the sick, but existing and in- 
creasing independently of human bodies, the comparatively 
protracted duration of the epidemic in one ward of a lunatic 
asylum, while it was spreading to other parts of the esta- 
blishment, seems to require some such assumption as that 
the poisonous matter attached itself to the surface of the 
walls, or furniture of the ward, or the clothes of the patients, 
and remained there for awhile, its quantity increasing more 
or less, and that while one portion of it was imbibed in 
some way or other by patients in the ward, another portion 
was conveyed to other parts of the establishment. Accord- 
ing to this view, too, the ultimate cessation of the disease in 
each ward must be ascribed either to the destruction of the 
poison by a spontaneous process, such as might be supposed 
to take place in the most simple vegetable organism, after 
it had thrown off germs, or to its destruction or removal, 
either by an altered state of atmosphere, or by the venti- 



32 ASIATIC CHOLERA. 

lating, cleansing, or other sanitary processes adopted. The 
hypothesis of the susceptibility of only a limited number of 
persons, would not here suffice to explain the entire cessa- 
tion of the disease, inasmuch as it would leave the cause 
of the disease still existing, and ready to affect any persons 
newly exposed to its influence. 

" If, then, the doctrine of contagion be rejected, it is un- 
doubtedly difficult to find a mode of explaining the cessation 
of the epidemic in each limited spot which would not be 
simply conjectural." 

The outbreak of the cholera in the school for pauper 
children at Tooting in England, gives a striking example of 
the communicability of the disease from individual to indi- 
vidual. The malady commenced in the school on the last 
two days of December, 1848, and in consequence of the 
great mortality among the children it was determined to 
distribute them in the parishes to which they belonged. 

" In four known instances fatal attacks of the epidemic 
occurred immediately in the workhouses or other asylums 
into which the infected children were received, and the out- 
break of the disease in a fifth institution was traced to com- 
munication with one of the dispersed parties of children. 

" Forty-five of the children being removed on the 6th or 
7th of January to the Bellevue-House Pauper Asylum at 
Margate, one of them died there on the 8th January ; and 
immediately afterwards several inmates of the house, who 
had not come from Tooting, were attacked, and three died 
two on the 11th and one on the 23d. 



ASIATIC CHOLERA. 33 

"At the Koyal Free Hospital, 155 of the children were 
received from Tooting on the 5th January ; four of them 
died between the 6th and 8th of January; five of the 
attendants were attacked, and two of them died between 
the 13th and 20th of the month."* 

One of the attendants at the Eoyal Free Hospital, who 
was attacked with cholera, died at the Holborn Union 
Workhouse, and the disease at the same time broke out in 
the latter institution. Similar results were observed in the 
St. Pancras Workhouse, and in Park-House at Hackney, 
showing that the disease was traced immediately to the 
advent of the pauper children. 

On the 17th July, 1832, two females left New York, 
then infected with cholera, for Newport, where they arrived 
the next day. They were detained one week in Quarantine, 
and on the 25th permitted to land, when both were found to be 
sick of spasmodic cholera, which proved fatal. On the 30th, 
Mr. Forbes, who had helped bury them, had bilious colic, 
and after several recurrences of symptoms, was restored to 
health. Subsequently four members of his family had 
cholera, and his wife and two children died. The first sub- 
ject of the disease was a nursing child, who died on the 4th 
of August. Two hospital nurses, living in Newport, also 
had the disease and died ; both of them had been employed 
at the house of Mr. Forbes. At the time of the appearance 
of the disease Newport was healthy, and Mr Forbes's house 
was in a healthy part of the town. 

* Baly and Gull, pp. 166 and 161. 



34 ASIATIC CHOLERA. 

Such instances as the preceding are numerous in every 
epidemic. 

An argument against the communicability of cholera by 
human intercourse, is based on the assertion, that the at- 
tendants of those sick with the disease do not contract it, 
or if so, the instances are rare. The evidence on this point, 
however, shows that there is undoubted reason to believe 
that attendants are more liable to contract the malady than 
those less exposed.* 

" T"ie instances are very numerous in which the com- 
munication of cholera by single patients laboring under the 
disease, is supported by evidence which it is scarcely reason- 
able to doubt."f 

During the recent epidemic at Ancona, a city of 46,227 
inhabitants, fourteen physicians lost their lives, and the Sis- 
ters of Charity were decimated. In this visitation, the 
total number of deaths was 1346 of the entire population. 

The irregular progress of the disease — sometimes against 
the wind, and again, leaving towns in its route and passing 
on to others, to return again to the first ; as well as the cir- 
cumstance that those who might be supposed, from accli- 
mation, to enjoy an immunity from attacks, are often early 
victims — these are all facts most readily explained by sup- 
posing that the pestilence is carried by man, particularly as 
other explanations are insufficient, while this is entirely ade- 

* See Report of Massachusetts Medical Society, pp. 58, 69. 
Boston, 1832. 

f Baly and Gull, p. 186. 



ASIATIC CHOLERA. 35 

quate. This is also the most plausible method of explaining 
why the disease should sometimes spread during the winter, 
in defiance of what might be considered atmospheric ob- 
stacles, and why its rate of travel should correspond with 
the comparative speed of intercommunication and traffic in 
different countries. 

It may, therefore, be considered as a well established 
feature of cholera, that it is transmitted by human inter 
course ; yet the evidence also shows that direct contagion, if 
it ever occurs, is very uncommon. The labors of Pettenko- 
fer,* Snow, Delbriick, Budd, Griesinger, and others, have 
shown that the dejections from cholera patients, or those 
suffering from cholera diarrhoea, are a very frequent and, as 
they claim, the chief cause of the propagation of the disease. 
Griesinger says : " It is possible that the disease may be 
propagated by other methods, yet this is problematical, 
while it is certain that the dejections contain the infectious 
material." With reference to the same subject, Dr. Parkes 
writes : " On looking back to the epidemics I saw in India, 
I can perceive many points which are capable of explana- 
tion if the putrefying stools are the cause."f It is also 
believed that fresh stools are innocuous, and therefore that 
the dangerous element is developed during their putrefac- 
tion. 

* Yerbreitungsart der Cholera, von Max Pettenkofer. Munich, 
1855. 

f A Manual of Practical Hygiene, by Edmund A. Parkes, M.D., 
F.R.S. Lond. 1864. Page 433. 



36 ASIATIC CHOLERA. 

The germ of the last cholera epidemic in Munich is be- 
lieved to have been brought there by Italians, who had 
come from places where cholera existed, to the exhibition 
in the Munich Crystal Palace. These, by using the latrines 
of the Crystal Palace, infected them, and as they were also 
used by many others, the infection was carried to all parts 
of the city. 

Dr. William Budd, in a recent pamphlet,* gives a num- 
ber of very striking instances, in which the spread of cholera 
was arrested by an immediate disinfection of the discharges. 
Among other incidents, he narrates the following : 

" Immediate disinfection was tried, at my suggestion, in 
the same year (1854), at Fishponds, in the workhouse situ- 
ated there for the reception of the Bristol poor. 

"In 1849, cholera, brought in by a woman coming from 
an infected quarter in Bristol, killed, in this same work- 
house, more than 130 out of less than 600 inmates. 

"In 1854, although the pest was introduced into the 
workhouse three separate times, only eight died of it, and 
the total number of attacks was under thirty. 

" In the prison of Kaisheim cholera was introduced by a 
prisoner who died there. The sanitary conditions of the 
prison were as bad as possible, but the choleraic discharges 
were disinfected, and the result was, that only one of the 
500 other prisoners took the disease. 

" In the prison of Elrach, on the contrary, where no mea- 

* Memoranda on Asiatic Cholera ; its Mode of Spreading and its 
Prevention. By William Budd, M.D., etc. Bristol, 1865. 



ASIATIC CHOLERA. 37 

sures of this kind were taken, of 350 prisoners, fifteen per 
cent, perished. 

" At Traunstein, in Bavaria, in every case in which the 
rice-water discharges were disinfected by snlphate of iron, 
the disease ceased with the person first seized. 

" In conclusion, I may mention the case of a planter in 
the Island of St. Vincent's, who ascribes the almost entire 
escape of his laborers from cholera in the great epidemic of 
1853, to similar measures. "When cholera broke out on his 
estate, he encamped all his negroes on open ground, and by 
the advice of one of my friends, had a pit dug in the earth 
and deeply charged with chloride of lime, to serve as a recep- 
tacle for all discharges from the sick. The result was, 
that while the neighboring estates were all decimated by 
cholera, and some almost depopulated by it, this gentle- 
man's estate escaped with only a slight outbreak." 

Yet, admitting that the dejections of cholera are a very 
frequent cause of the disease, it is certain that their noxious 
effect depends to a great degree upon certain conditions. 

Pettenkofer thus defines his views as to the circum- 
stances which are essential for the development of a cho- 
lera epidemic :* 

1. "An inhabited stratum of earth which for a certain 
depth (the depth of the moisture in the soil) is sufficiently 
porous to admit of the diffusion of air and moisture. 

* Beilage zur Allgemeinen Zeitung, October 8th, 1865. See the 

same journal from October 1st to October 10th. I am indebted for 

these numbers to Dr. M. Herzog, of this city. 

3* 



38 ASIATIC CHOLERA. 

2. " An occasional decided variation in the quantity of 
this moisture. This is best observed in the varying quan- 
tity of water held in alluvial soils, and here the period when 
the moisture recedes from an unusually high level is the 
period of danger. 

3. " The presence of organic materials, especially such as 
are formed from excreta with which the soil has become 
infiltrated. 

4. "The specific germ, transmissible by human inter- 
course, the ultimate cause of cholera, transferred principally 
in the dejections of those suffering from cholera diarrhoea ; 
perhaps also by persons in good health coming from in- 
fected districts. 

5. " A predisposition on the part of individuals to receive 
the disease."* 

The Commission appointed to prepare a report based on 
observations made throughout the whole kingdom of Ba- 
varia, during the cholera epidemic of 1854, decided "that 
all cases where the cholera has prevailed epidemically, stand 
on a porous soil which is permeated by air and moisture, 
and according to our present knowledge, the water lies at 
a depth of from five to fifty feet. This condition of soil 
seems necessary for the existence of an epidemic. In local- 
ities upon a compact rocky foundation, or upon rocks 
which contain no moisture, scarcely any instances of cho- 

* By this seems to be implied not a special predisposition, but 
those causes which ordinarily render individuals liable to disease ; 
as nervous depression, errors in diet, etc. 



ASIATIC CHOLERA. 39 

lera have been observed, at the most only individual cases, 
but not an epidemic." 

Dr. E. Harris, in a Keport on Epidemic Cholera,* gives 
the following results of observations made during cholera 
epidemics at the Staten Island Quarantine, as to the con- 
tagious properties of the rice-water evacuations : 

"In studying the history of fourteen epidemics of 
cholera that have occurred within the walls of our New 
York Quarantine establishment, the writer has seen abun- 
dant evidence of the infectious agency of the sick and their 
' rice water' evacuations. Ten of these epidemics at Qua- 
rantine unquestionably depended upon cholera patients 
from ships, and in six instances, at a time when there was 
no cholera upon our Atlantic coast. These sudden out- 
bursts of cholera, as a general rule, occurred within a 
period of four days from the disembarkation of the sick, 
and whenever cholera was not generally epidemic in this 
country, these epidemics at Quarantine ceased as suddenly 
as they came, after sweeping off a portion of the convales- 
cents and patients that were in other hospital buildings, 
having other diseases. The cholera patients were kept as 
remote from other patients as possible. 

"Concerning these repeated outbreaks of cholera at 
Quarantine, it should be stated, that while they proved how 

* Report on Epidemic Cholera by the Council of Hygiene and 
Public Health of the Citizens' Association of New York. New 
York, November, 1865. 



40 ASIATIC CHOLERA. 

fatally infectious the cholera poison may become in the 
midst of crowded hospitals and public institutions, they 
utterly failed to prove that from the same exclusive cause — 
viz. the contagion of the cholera evacuations — a world- 
wide epidemic could be caused. These outbreaks did 
prove, however, that the stools and besmeared clothing of 
the sick with cholera can, under certain circumstances, pro- 
pagate the disease ; while, on the other hand, a series of 
events at Quarantine and in the city demonstrated, that 
for the production of a wide-spread epidemic, other impor- 
tant causes than the presence of the ' rice-water' stools and 
vomitings must be present." 

Those instances in which the disease has ravaged a cer- 
tain locality during one epidemic and passed by it in a 
succeeding one, although prevailing in its neighborhood, 
Pettenkofer explains by the varying level of the water in 
the soil, and this water or moisture he considers as the 
chief localizing cause of cholera. 

This theory is supported by many very striking facts,* 
and explains, among other circumstances hitherto difficult 
to understand, why the disease, contrary to its usual affinity 
for low and marshy soils, has prevailed at very considerable 
elevations. In Flintern, the principal cholera field of Zurich, 
where the epidemic raged 400 feet above sea level, while 
sparing the adjacent low ground, an abundance of water 
was found, on boring, at a depth of only ten feet, A 
humid soil is also supposed to have afforded a localizing 

* Beilage zur Allgemeinen Zeitung, Oct. 2d and 3d, 1865. 



ASIATIC CHOLERA. 41 

cause for the epidemics which have prevailed during the 
winter.* 

Yet some writers consider that the existence of all epi- 
demics of Cholera cannot be explained on this theory. 
Kiehlf says that cholera has prevailed in Hindostan on a soil 
where every trace of vegetation was destroyed, and not even 
a blade of grass could find nourishment. Dr. Drasche, in his 
monograph on cholera, also gives a number of instances in 
which the disease prevailed epidemically without regard to 
the moisture in the soil, and even on the bare rock. Dr. 
R. Lorange, physician to the Johannes Hospital in Beyroot, J 
who has been in that city during the recent epidemic, also 
finds Pettenkofer's teachings insufficient to account for the 
prevalence of the disease there. He states that it is a city 
renowned for healthfullness, and the soil is unusually free 
from moisture. During the summer there is a deficiency of 
water, and the wells which indicate the level of the water 
in the soil (these contain a greater or less quantity of salts 
of lime) are at a depth of eighty feet or more. The stra- 
tum on which Bey root lies is a moderately fragile limestone, 
with an occasional vein of flint, and the earth is so thin that 
in many places the houses stand upon bare rocks. He 
adds that the diet of the Orientals is bad. Their cooked 
dishes are almost always too complicated and greasy, and 



* Moscow and Orenburg, 1830 ; Prague, 1831 ; Ancona, 1846 ; 
Staten Island Quarantine, 1848; St. Petersburgh, 1852 and 1853. 
f Ueber den Ursprung, etc., p. 349. 
% Berliner Klinische Wochenschrift, November 6, 1865. 



42 ASIATIC CHOLERA. 

fruits and vegetables are preferred by the poorer classes in 
an unripe or raw state. The interval between the morning 
and evening meal is too long ; and the fasts of the Christians, 
as well as the Mahommedans, contribute to the production of 
intestinal catarrhs. In summer, a large part of the popula- 
tion passes the night in the open air. There are no sanitary- 
regulations worthy of the name, and Dr. Lorange is at a 
loss to know how, if Pettenkofer's teachings with regard to 
the dejections of cholera are correct, the epidemic might 
not continue indefinitely, since there were, at the time of 
writing, so many infected privies and 800 badly buried corpses. 
To these maybe added some interesting facts with regard to 
the cholera as it appeared in Beyroot in 1855, for which 
Dr. W. H. Thomson, of this city, who was there at that 
period, is authority. On the east side of the city there are 
large vineyards, which are irrigated by a river which comes 
from the mountains behind. Intermittents are very com- 
mon in that locality. The western extremity of the city is 
more healthful, and in that vicinity the excrements and 
refuse of the city are deposited ; it is a kind of dumping 
ground. The cesspools of Beyroot run from the houses 
into receptacles in the streets ; these receptacles are emptied 
by a class of men called zibbals, who carry away the ex- 
creta in large panniers upon the backs of donkeys to the 
dumping ground. Sometimes the zibbals also ride upon 
the load. During the epidemic nearly all of these men died 
of the disease, and the cholera prevailed with much greater 
violence on the west side of the city, usually the more 



ASIATIC CHOLERA. 43 

healthful, but near which the refuse of the city was de- 
posited, than on the east side, infected with malaria, and, 
ordinarily, more unhealthful. Such facts seem to show that 
a cholera epidemic may prevail upon a dry and rocky stra- 
tum, in which the moisture lies more than fifty feet below 
the surface, when it appears among a people careless of the 
ordinary laws of health and in the vicinity of an abundance 
of decaying excretions ; also, that such excretions favor the 
spread of cholera more than a malarious atmosphere. At 
the same time, the fact that the disease was not indefinitely 
protracted does not weaken the theory that the dejections 
contain the infectious material, for the striking mortality 
among the scavengers in Beyroot is an additional argument 
to the many more in its favor ; it only proves that the laws 
upon which the duration of a cholera epidemic depend are 
still unknown. 

Whether the cholera principle is transferable in clothing 
and the cargoes of vessels, except as these may have been 
defiled by choleraic dejections, is still a debatable question. 
M. Grimaud relates the following incidents of the recent 
epidemic which he considers reliable : 

" A peasant died of cholera near St. Jean du Desert, at 
St. Pierre, not far from Marseilles, in an isolated place, and 
his wife also died. He had not left the country, but, Dr. 
Dussiller states, that his wife was a laundress, and had re- 
ceived a bundle of linen belonging to an individual recently 
arrived from Egypt. It was the husband who opened 
the bundle and unfolded all the pieces." There is 



44 ASIATIC CHOLERA. 

very good reason for supposing that this clothing was 
defiled. 

The next case which he narrates is still more interesting, 
since there is not the same probability of contact with 
cholera dejections : 

"The postal department of Marseilles numbers 120 per- 
sons, of whom seventy-five to eighty are clerks ; twenty-two 
are employed at the bureau of departure, and nine at the 
bureau of arrival. There has not been a single death, or even 
a case of sickness, at the former bureau, while of the latter 
nine employes, eight have been sick and one has died. 
These eight have been taken sick one after the other ; this 
has been proved of the first five. The one who opened the 
dispatches from the East fell sick, was ' cholerise,' another 
was put in his place, the same effect followed, and so on up 
to the fifth." * 

The custom has been adopted in the East, during epi- 
demics of cholera, to send the mail in boxes, on the sup- 
position that they are less likely to carry infection than 
bags. 

From a personal experience of a two-weeks quarantine in 
the port of Messina, it may be stated as a custom of the 
authorities there to fumigate with sulphur all letters from 
those in quarantine who have left ports supposed to be 
infected with cholera. This custom may be supposed to 
have been adopted as the result of experience. With regard 

* Boston Med. and Surg. Journal, Thursday, December 21, 1865. 



ASIATIC CHOLERA. 45 

to the transmission of the disease in cargoes, it has been 
noticed, in connexion with the epidemic on the Atlantic, 
that " thousands of boxes of merchandise not only came 
from Paris, but from Marseilles, Toulon, and Barcelona, 
while cholera was prevailing as an epidemic there, without 
producing the disease in a single instance." * 

The opinion of physicians in Europe has been tending 
towards a belief in the contagious nature of cholera. Dur- 
ing the last epidemic in Paris, the cholera patients were 
treated in separate wards, and the administration ordered 
the immediate removal, cleansing, and disinfection of the 
bedding used by cholera patients, as well as the washing 
and fumigation of the personal clothing. 

M. Velpeau considers the contagious character of the 
disease proved to a certainty, and the same is true of other 
prominent European physicians. M. Jules Worms, chief 
physician of the military hospital of Gros-caillou, is also of 
this opinion, and presented the following views on the 
method by which cholera is propagated at a meeting of the 
French Academy of Medicine, held on the 10th of Octo- 
ber: 

" On the banks of the Ganges, and under conditions 
which are not well understood, a special agent, poisonous to 
a large number of individuals, is produced. 

" This agent shows itself among individuals who are col- 

* See letter in N. Y. Herald from Theodore "Walser, M.D., Novem- 
ber 6, 1865. 



46 ASIATIC CHOLERA. 

lected together in rest or motion, but always presents an 
uninterrupted connexion. 

" The cholera is a malady transmissible by man. 

"This agent manifests its influence on certain human 
beings (probably also on certain animals) by mild or severe 
effects. 

" The proportion of individuals liable to the poison can 
only be approximately estimated, and is under all circum- 
stances very small. The human system may become a 
fruitful field for the multiplication of this agent as soon as 
its poisonous effects are manifested. 

" The multiplication of this poisonous agent takes place 
chiefly in the alimentary canal. 

"The vomitings and dejections of cholera patients con- 
tain the active agent of the transmission of the disease. 

" This communicability does not correspond to the time 
when the dejections are voided, but is developed a few 
days subsequently, and seems to be exhausted at the end of 
from fifteen days to three weeks. 

" The corpses of cholera patients emit the toxic agent in 
a greater degree than the bodies of the sick. 

"Persons attacked merely with choleraic diarrhoea (cho- 
lerine) void with their dejections the agent which is capable 
of producing confirmed cholera in their vicinity. 

" The greater or less density of the soil on which the 
dejections are cast diminishes or favors the propagation of 
the disease."* 

* Archives generates de Medecine, Nov. 1865, p. 623. 



ASIATIC CHOLERA. 47 

In proportion as further study reveals more of the essen- 
tial nature of cholera, unexplained phenomena will be- 
come clearer, and apparent discrepancies reconciled. 
Something has been already accomplished in this direction, 
and the following important propositions, which are sus- 
tained by sufficient evidence to justify a belief in them, are 
the results of comparatively recent investigations : 

First Cholera is a disease which is diffused by human 
intercourse. 

Second. The cholera dejections are the chief (if not ex- 
clusive) agents in disseminating the infectious material. 

Third. Certain circumstances, among which moisture in 
the soil has a prominent, but not exclusive, part, favor the 
spread of the disease. 



48 ASIATIC CHOLERA, 



CHAPTER III. 

In the study of the prevention of cholera, the inquiry at 
once arises, where does the disease usually prevail with the 
greatest violence, and what class of the population is most 
liable to its attacks ; while with regard to this country, the 
additional circumstance, that the pestilence has always 
been brought here in a comparatively few ships, across a 
wide ocean, also deserves consideration. The general testi- 
mony as to the chosen haunts of choleia is quite unani- 
mous. It is in low, dark, damp, over-crowded dwellings, 
and among the ill-fed, badly clothed, filthy, and dissipated, 
that the disease makes the greatest ravages. Dampness, filth, 
impure water, over-crowding and deficient ventilation, dissi- 
pation, poverty, fatigue, and improper food, favor the 
advance of cholera ; they are causes which produce 
depression of the nervous system and irritation of the 
alimentary canal.* 

Sometimes, it is true, the disease has shown an apparent 
inconsistency. At first raging with great fury in filthy 
localities, it has passed by others which were near and equally 
insalubrious, and has then attacked places where the sani- 
tary condition was comparatively good. Yet this is simply 
one of those seeming contradictions in cholera, which is 

* Report on Asiatic Cholera, by William Baly r M.D., F.R.S. 



ASIATIC CHOLERA. 49 

easily reconciled on the supposition that the infectious 
material is transported in the dejections. Such instances 
do not weaken the fact that "the very general association 
of cholera where it is rife (is) with over-crowding and 
deficient ventilation, imperfect drainage, want of clean- 
liness, and the effluvia from privies, cesspools, foul drains, 
&e."* 

As is well known, the recent epidemic in Constantinople 
was accompanied with great loss of life. The sanitary 
condition of that city is extremely defective. All offal 
and filth is thrown into the streets, and what is not con- 
sumed by the dogs, remains under a burning sun, a heap 
of putrefying animal and vegetable matter. The only 
drains are open ditches in the middle of the narrow streets ; 
and the Turkish houses are, as a rule, wanting in the most 
necessary conditions of health. Crowded burial grounds 
are another fruitful source of epidemic disease, especially 

* The localizing causes of cholera are thus further specified in 
the Report of the Council of Hygiene on Epidemic Cholera, 
page 19. 

1. Decaying organic matters, bone, hide, fat and offal houses, neg- 
lected stables, putrescent mud and filth. 

2. Bad drainage, local dampness, malaria. 

3. Obstructed sewers, filthy streets, gutters, stables, garbage, and 
cesspools. 

4. Water and beverages in any manner contaminated by putres- 
cent organic matter, particularly by any soakage from privies. 

5. Neglected privies and putrefying excrements. 

6. Overcrowding and neglect of ventilation. 



50 ASIATIC CHOLERA. 

as the Turks, from a religious superstition, seldom bury 
their dead more than two feet below the surface.* In the 
presence of such conditions it is not a matter of surprise, 
that during the prevalence of an epidemic of cholera the 
mortality was so great, f 

It is also an interesting feature connected with cholera, 
that a second epidemic will sometimes commence in the 
same house where the first began, even in the same room. 
Thus in Toeplitz the cholera broke out in the same house, 
near a canal, two years in succession. In Edinburgh one 
of the first two cases which occurred in 1848 was in the 
same house where the malady had first appeared in 1832, 
while in Leith ir> 1832 and 1848 the disease commenced in 
the same room. The epidemic in Rheims of 1849 and 
1854 also originated in the same house. 

A low level of the soil is usually associated with a defi- 
cient drainage, and under ordinary circumstances damp ; J 
while the deadly influence of poisoned air, such as is found 
in filthy over-crowded dwellings, has forced itself upon the 
notice of the inhabitants of tenant houses, and its effects 
have been characterized by themselves in striking language 
as " tenant house rot." During a cholera epidemic, such 



* Medical Times and Gazette, October 1th, 1865. 

f The mortality is placed at from 30,000 to 58,000. 

\ Mr. Farr found that in proportion as the mortality from 
cholera increases, the elevation of the soil is as a general rule 
lower. 



ASIATIC CHOLERA. 51 

an atmosphere would be far more deadly from the presence 
of the poisonous dejections. 

Bad food, less common here than in other countries, 
scanty clothing, darkness, and dissipation, dispose to any 
disease by diminishing nervous resistance. During the 
prevalence of cholera there is a general predisposition to 
looseness of the bowels, likely, if unchecked, to run to a 
grave termination, and this is aggravated by improper food, 
or water impregnated with organic or excrementitious matter. 

The agency of impure water in increasing the mortality 
from cholera has been very strongly marked, and in Paris 
the idea prevailed during one visitation of the malady, 
that the waters of the city had been poisoned. Dr. Snow, 
of London, believed that the cholera was propagated to a 
great degree by means of water ; his theory, however, 
included more than this, and was as follows : Cholera is 
pathologically a disease exclusively of the alimentary canal. 
The primary change is in the alimentary canal, and is 
always caused by the introduction into it of a specific 
poison. The poison itself is exclusively contained in the 
intestinal excreta of the infected person ; that is, in the 
vomit or dejections. There is nothing from the lungs or 
skin that produces the disease. This poison is not a gas or 
vapor, but a substance capable of existence in the fluid or 
dry form of matter ; hence it can only be wafted a little 
way by the air, and when in the dried state can only be 
carried long distances by being attached to articles of cloth- 
ing, or disseminated by the agency of water. 



52 ASIATIC CHOLERA. 

The methods of propagation are four in number : 

1st. Moist excreta on clothes and bedding of infected 
persons, may be carried by the vapor of water and enter 
the nostrils and mouth and be swallowed. 

2d. Dry excreta on infected clothing may be wafted a 
short distance by the air when the clothing is moved or 
unfolded. 

3d. Nurses and those who attend the sick may introduce 
the poison into their system by not washing their hands 
before taking food. 

4th. Utensils used by the sick and not properly cleansed 
may also contain the germ of the disease. 

The same objections may be made to this as to some 
other theories on cholera : that they are too exclusive. 
Is it safe to assert that the poison is exclusively contained 
in the intestinal excreta, or that it is not gaseous or a vapor, 
when it is so subtle as to have eluded the most searching 
examinations ! Some points in this theory seem to be 
substantiated, as that the poison is (mainly) contained in 
the excreta, and that it may be carried on clothing or food ; 
hence it is better to admit what is known, and patiently 
follow the teaching of facts in a further elucidation of 
those features of the disease which are as yet unknown. 

To return from the digression ; it has been observed 
that the cholera has shown the same affinity for moist and 
unhealthy localities, when visiting this country as in other 
lands. Those localities where fever, diarrhoea, and dysentery 
prevail, are also the haunts of cholera. 



ASIATIC CHOLERA. 63 

The first epidemic made its appearance in this city in 
the vicinity of Roosevelt and Cherry streets, and at the 
same time it appeared in Beade, Washington, and Duane 
streets. The Five Points and the whole region of the 6th 
Ward, were visited by the epidemic with fearful virulence. 
In 1849 it commenced in Baxter street, and quickly extend- 
ed to the 1st, 4th, 5th, and 13th Wards. In Philadelphia 
it appeared in the districts of Moyamensing and South- 
wark, where the work of cleansing was incomplete. In 
Boston the epidemic began in Hamilton street, and spread 
through such places as Ann, Cove, Hanover, and Sea streets. 
At Louisville, Ky., the centres of the epidemic were asso- 
ciated with filth, malaria, and crowding ; the same we s 
. true of Buffalo, New Orleans, and other cities. 

The inference from the preceding is, that all towns, and 
especially sea-ports, should be placed in the best possible 
sanitary condition, since by this method the influences of 
those causes which favor the spread of the disease may be 
very much diminished. At the same time, as there is good 
reason to believe that the disease is chiefly propagated by 
choleraic discharges, these should, in the event of an epi- 
demic, be at once disinfected, and the advance of the pesti- 
lence contested step by step. 

Low, moist places, should be thoroughly drained ; yet 
this should be done before the appearance of an epidemic ; 



* See Sanitary Condition of New York, Report of Council of 

Hygiene ; Citizens' Association, page briii (Mote.) 

4 



54 ASIATIC CHOLERA. 

for it is often observed that in very dry seasons, malarial 
fevers prevail in consequence of the drying up of marshes 
or ponds ; and there is every reason to believe that malaria 
and cholera devastate the same ground. Hirsch says it is 
a well known fact, that malarial fever has preceded out- 
breaks of cholera not only in single places or particular 
regions, but in an almost pandemic distribution. Dr. R. 
Lorange, Physician to the Johannes Hospital, also states 
that during the recent epidemic in Beyrout, before the dis- 
ease had reached its height, there appeared what he terms 
a gastric, rheumatic, remittent fever, of an epidemic cha- 
racter. The fact that malarious districts are favorable to 
the spread of cholera, does not necessarily imply an iden- 
tity between the agencies which develop malaria and 
those which produce cholera ; since it may only indicate 
that circumstances which favor one may also favor the other. 

A very strict watch should be kept over those localities 
in which previous epidemics of the disease have commenc- 
ed ; and if necessary they should be thoroughly cleansed. 

During the prevalence of cholera the greatest house- 
hold and personal cleanliness should be observed ; yet all 
street, pavement, and house cleaning should be done, as far 
as is possible, without water, by what is called dry cleans- 
ing. Fires should be kept in damp places. Persons inha- 
biting damp localities should, if possible, leave them tem- 
porarily for dry ones ; and it is in general desirable that 
those whose presence is not needed during an epidemic, 
should, if circumstances permit, go to some dry or health- 



ASIATIC CHOLERA. 55 

fill neighborhood ; as in this manner a larger supply of fresh 
air is left for those remaining, while the number exposed to 
the disease is also lessened. This is particularly important 
in the case of pregnant women. 

The effect of poisoned air from unavoidable over-crowd- 
ing, may be diminished by keeping windows open, the en- 
tire dwelling being thoroughly ventilated ; since it is believ- 
ed that fresh air is the best disinfectant. At the same time, 
since the best air in certain localities is bad, disinfecting 
substances should be used in connexion with free ventila- 
tion. Drains should all be provided with good traps, and 
drains and sewers often flushed and disinfected. Garbage 
should be speedily removed or disinfected by chloride of 
lime, or some similar agent, if there is delay in its removal. 
It is also of the greatest importance that privies should be 
thoroughly disinfected as often as twice daily during the 
prevalence of an epidemic. This is particularly required 
for public latrines, such as those of hotels, saloons, schools, 
factories, and railroad stations ; and it would be a proper 
precaution for strangers coming from infected districts, to 
make a free use of disinfectants, particularly if suffering 
from diarrhoea. 

The sick, and the appurtenances of the sick room, should 
be isolated from all but the necessary attendants, and the 
room well ventilated. At the same time it is advisable to 
place dishes containing chloride of lime in the vicinity of 
the patient ; since it has been inferred from experiments 
made in hospitals that this agent hinders the propagation 



56 ASIATIC CHOLERA. 

of the disease by neutralizing those conditions which favor 
its advance.* Yet a disinfectant in a closed room does not 
take the place of fresh air. 

The dejections and vomitings should be received into 
vessels containing either permanganate of potash, carbolate 
of lime, a solution of chloride of zinc, sulphate of iron, or 
some other active disinfectant, and be at once removed. If 
the discharges have been ejected upon the bed, they should 
be sprinkled with some disinfectant, as Labarraque's solu- 
tion. It is also recommended to place a bag (folded cloths) 
containing a sufficient quantity of Condy's or Macdougall's 
disinfecting powder, under the breech of the cholera pa- 
tient to disinfect involuntary discharges. The privy into 
which the dejections are cast should be used exclusively for 
that purpose, all utensils of the sick room kept scrupulous- 
ly clean, and attendants should wash their hands before tak- 
ing food. 

In country towns it would be preferable to place the dis- 
charges in a pit containing chloride of lime, and cover 
them with earth. The bed and body linen of the sick 
which cannot be disinfected should be burned. Boiling 
water is a powerful disinfectant of clothing defiled with 
cholera discharges: Yet since individuals exposed to the 
vapor of hot water containing such clothing, as washer- 
women, have in many instances contracted cholera, perhaps 
from that source, it would be advisable to add some disin- 

* Gazette des Hopitaux, Nov. 16, 1865. 



ASIATIC CHOLERA. 57 

fectant to the water into which the clothing of the sick is 
immersed. 

After the cessation of the disease the sick room should 
be thoroughly cleansed and fumigated ;* in fine, a kind of 
domestic quarantine should be established, since from in- 
stances afforded by the present and past epidemics, there 
is reason to believe in the efficiency of such a method.f 

The following suggestions, by Dr. E. Harris, concerning 
" How to use disinfectants," are introduced for easy refer- 
ence. J 

" 1. Quicklime. — To arrest putrefaction, to act as a rapid 
dryer, and to decompose certain moist and hurtful effluvia, 
strew the dry lime upon the earth ; or, distribute upon 
plates, etc. 

" 2. Chloride of Lime. — Employ this for same purpose 
as quicklime, also as one of the cheapest sources of chlo- 
rine. One pound of this substance will usually disinfect 
about 1,000 gallons of fluid sewerage. To mix immedi- 
ately with offensive materials, it may, for convenience, be 
combined with water in proportion of 1 lb. to the gallon. 

"3. Chloride of Zinc, Pro to- Chloride of Iron, Sulphate 
of Iron, or Nitrate of Lead. — Make a saturated solution 

* Liebig recommends burning sulphur for this purpose. 

f Copland's Medical Dictionary, Lond. 1858, Yol. III. Part 1, p. 115 ; 
also Memoranda on Asiatic Cholera, etc., by "William Budd, M.D., 
Bristol, 1865 ; also Medical News and Library, Feb. 1866, No. 278 ; 
also Med. Times and Gazette, Nov. 17, 1855. 

% Report on Epidemic Cholera, Council of Hygiene, Citizens' As- 
sociation. 



58 ASIATIC CHOLERA. 

of the salt, and use such solutions diluted in eight or ten 
times the quantity of water. 

" 4. Chlorine Gas. — When required more copiously than 
it would ordinarily be given off by the chloride of lime, 
or Labarraque's solution, the following ready methods may 
be resorted to for generating it. For the ordinary methods 
see books of chemistry. 

" Quick Method. — Pour dilute hydrochloric, sulphuric, 
nitric, or acetic acid, upon chloride of lime, zinc, or soda. 
This may be done gradually by means of a glass or lead 
syphon, or by the capillary syphon or lamp-wick, dropping 
the acid upon the chloride, if desirable to evolve the chlo- 
rine steadily for many hours. 

" Chlorine water may be readily prepared by mixing 
two tablespoonfuls of common salt in two teaspoonfuls 
of red lead in a quart of water, and add half a wine- 
glass of sulphuric acid. It will give off gas as needed. 

" It must be borne in mind that chlorine is irritating to 
the lungs. It is believed not to disinfect and destroy the 
cholera poison itself, but it arrests putrefaction and 
destroys many noxious gases. 

" 5. Nitrous Acid Gas. — This is prepared by putting a 
mixture of nitrate of potassa (saltpetre) and sulphuric 
acid in an iron or porcelain dish. It must not be breathed. 

" 6. Coal-Tar. — To be used in sinks, sewers, privies, 
and bed-pans, by directly applying it, and allowing it to be 
washed away. It serves an excellent purpose when 
painted frequently upon the interior walls or sides of sta- 



ASIATIC CHOLERA. 59 

bles, prison cells, privy vaults, etc. Carbolic acid is derived 
from coal-tar, and is more convenient for use in the sick 
room. Dilute it. 

" 7. Bromine, — Is a powerful disinfectant ; to be em- 
ployed by physicians. 

" 8. Permanganate of Potassa. — To be used as an imme- 
diate and most effective disinfectant. Dilute the satu- 
rated solution of this salt in from 10 to 500 parts of 
water, according to the requirements for the occasion. It 
is the neatest and most effectual of all the disinfecting 
fluids, and can be used in less quantities than most others. 
A few drops of the solution will instantly disinfect a quart 
of drinking water. 

" 9. Heat. — Boiling water or steam to be employed in 
cleansing as the most certain means of disinfecting con- 
taminated clothing, etc. 

" 10. Charcoal. — As a disinfectant or deodorant for 
extensive use in masses of putrescent material, and for 
local purification, fresh charcoal is of acknowledged value. 
The British Sanitary Commission in the Crimea ordered 
whole ship-loads of peat-charcoal, which they used in the 
progress of their work of purification in the hospitals, bar- 
racks, and camps in the East. A Report of that Com- 
mission states that ' perhaps the best deodorizing com- 
pound was one used by the inspectors in all their works. 
It consisted of one part of peat charcoal, one part of 
quicklime, and four parts of sand or gravel.'' But it 
may properly be stated in this Report that charcoal does 



60 ASIATIC CHOLERA. 

not seem to disinfect or destroy the cholera poison. The 
ships which were employed in transporting charcoal from 
Constantinople to the Crimea were ravaged by cholera." 

To the above may be added the advice of the Privy 
Council of the British Government on the same subject : 

" In the ordinary emptying of privies or cesspools, use 
may be made of perchloride of iron, or chloride of zinc, 
or of sulphate of iron. But where disease is present, it is 
best to use chloride of lime or Condy's fluid. Where it is 
desirable to disinfect, before throwing away the evacuations 
from the bowels of persons suffering from certain diseases, 
the disinfectant should be put into the night-stool or bed- 
pan when about to be used by the patient. 

" Heaps of manure or other filth, if it be impossible or 
inexpedient to remove them, should be covered to the 
depth of two or three inches with a layer of fresh burnt 
vegetable charcoal in powder. Freshly burnt lime may be 
used in the same way, but is less effectual than charcoal. 
If neither charcoal nor lime be at hand, the filth should be 
covered with a layer some inches thick of clean dry earth. 

" Earth, near dwellings, if it has become offensive or 
foul by the soakage of decaying animal or vegetable 
matter, should be treated on the same plan. 

" Drains and ditches are best treated with chloride of 
lime, or with Condy's fluid" (permanganates), " or with 
chloride of iron. 

" Linen and wearing apparel requiring to be disinfected, 
should without delay be set to soak in water, containing 



ASIATIC CHOLERA. 



per gallon, about one ounce either of chloride of lime or of 
Condy's red fluid. The latter, as not being corrosive, is 
preferable. Or the articles in question may be plunged at 
once into boiling water, and afterwards when at wash be 
actually boiled in the washing water. 

"Woollens, bedding, or clothing, which cannot be 
washed, may be disinfected by exposure for two or more 
hours in chambers constructed for the purpose, to a temper- 
ature of 210 to 250 degrees Fahrenheit. 

" For the disinfection of interiors of houses, the ceilings 
and walls should be washed with quicklime water. The 
wood-work should be well cleansed with soap and water, 
and subsequently washed with a solution of chloride" 
(permanganates) "of lime, about two ounces to the 
gallon." 

The question of diet is one which has been the theme of 
much discussion. The Cholera Commission of Munich in 
1854 addressed the following inquiry to the physicians of Ba- 
varia : " What food and drink seem to have furthered the 
outbreaks of the disease ?" The result of the replies was a 
list of all the various articles of diet consumed throughout 
the kingdom. Yet there are certain kinds of food which 
are to many persons difficult of digestion at ordinary times, 
and it is the part of prudence for all to avoid these during 
an epidemic of cholera. As examples, are cabbages, cucum- 
bers, turnips, green corn, cherries, apples, plums, whortle- 
berries and milk, green vegetables, and all kinds of unripe 

fruit. To this list may be added crabs, oysters, clams, lob- 

4* 



62 ASIATIC CHOLERA. 

sters, and fresh pork. On the other hand, a diet which is 
in general terms nutritious and easily digestible, is to be re- 
commended ; and bread, rice, beef, mutton, and poultry, with 
a moderate use of thoroughly cooked ripe potatoes, are ex- 
amples of articles which are nutritious and easily assimilat- 
ed. Certain sub-acid fruits, as ripe currants, are considered 
by some as actually beneficial. An excessive use of starchy 
food is not desirable. It is perhaps worthy of mention 
that beef tea often produces a relaxation of the bowels, in 
which case mutton broth may be substituted. 

Yet the details of diet must be varied to meet particular 
cases, and that which one may eat with impunity would be 
most injurious to another. The object to be attained is to 
repair the waste of the body by an unirritating and easily 
digestible diet. 

Water used for drinking should be boiled or filtered, and 
as pure as can be obtained. 

In addition to the preventive measures previously men- 
tioned, the custom of wearing a flannel band sufficiently 
large to cover the abdomen, is most excellent. This is very 
important in the case of children, since the flannel shirts 
which they wear are an insufficient protection, and with the 
varying movements of the child the shirt often becomes 
rolled up upon its chest. The feet should be kept dry, and 
night air avoided. Mental anxiety should be laid aside as 
far as possible, and cheerfulness and calmness cultivated ; 
since the influence of fear in predisposing to attacks of 
cholera is generally acknowledged. It has also been ob- 



ASIATIC CHOLERA. 63 

served that the insane are more liable to choleraic infection 
than those of a healthy nervous organization, and the wise 
man has said, what the experience of every physician con- 
firms, that " a merry heart doeth good like a medicine." 

An objection to cholera hospitals (houses of refuge) is, 
that the disease seems to spread from their vicinity. Yet 
the poor and friendless must be cared for somewhere. If in 
their own unhealthy homes, the chances of their recovery 
are diminished; while in consequence of their careless ha- 
bits the disease is likely to become epidemic in that locali- 
ty, or be carried to other neighborhoods. If in general 
hospitals, experience has shown that cholera extends in the 
wards, and the fear of receiving the malady would operate 
unfavorably upon those sick with other complaints. There- 
fore by centralizing and isolating the disease, and placing 
cholera patients in large, cleanly, and well ventilated wards, 
a benefit would be conferred upon the sick, and the danger 
to the health of the community diminished. The removal 
should be effected as gently as possible, and for this pur- 
pose biers are preferable. 1 * 

When the circumstances permit the use of tents they are 
the best hospitals. Dr. Parkes says : " Men sick from cho- 
lera are also best treated in well ventilated tents ; cholera 
wards and hospitals do not answer. Even in cold countries, 
up to the end of October or the middle of November, tents 
can be used if properly warmed."f 

* Dr. Drasche. 

f The expression that " Cholera wards and hospitals do not an- 



64 ASIATIC CHOLERA, 

Instances of the treatment of cholera in tents are of the 
most interesting character. The two hospital buildings in 
Varna received from the 10th of July to the 18th of Sep- 
tember 1854, 2314 cholera patients, of which 1389 died, 
a mortality of 60 per cent. In the three tent hospitals in Varna 
and Franka there were also received, from the 5th of Au- 
gust to the 19th of September, 1854, 2635 cholera patients, 
of which 698 died, or a mortality of 26 per cent. Besides, not- 
withstanding vigorous hygienic measures, the hospital build- 
ings remained full of infection, while this was not the case 
in the tents. In the hospitals of Gallipoli, Adrianople, and 
Varna, 1 7 physicians lost their lives, while not one of those 
physicians in charge of the tents took the disease. 

In 1854, when the cholera appeared in the hospitals of 
Pera and Rami-Tchifflick, in Constantinople, M. Levy im- 
mediately removed all cholera patients from the hospital 
buildings into tents ; this was twice rendered necessary, and 
each time the epidemic came to a speedy termination. 
About the end of October the bad weather made it impos- 
sible to continue the care of the cholera patients in tents, 
and as a result of the change 14 cases of cholera sicca ap- 
peared ; while before the return of the patients to the wards 
of Rami-Tchifflick, there had not been a single instance of 
this form. 

swer," is to be understood comparatively, since they are better 
places for the sick than their own ill- ventilated abodes. The compa- 
rison is between tents for hospital purposes and ordinary hospital 
buildings. 



ASIATIC CHOLERA. 65 

In the Austrian army and in Berlin, similar favorable re- 
sults have been observed. 

Systematic house to house visitations, in the commence- 
ment of and during an epidemic, have been found to diminish 
in a marked degree the general mortality. This experiment 
was tried in England, and statistics show that of 130,000 
cases visited, 6000 narrowly escaped real cholera, and only 
250 had the disease ; thus it would seem that the system 
of visitation prevented 5,750 cases of cholera. Dr. Gull, 
who examined this question very critically, states that the 
evidence " is sufficient to place the preventive system in 
the first position of importance, as a measure for counter- 
acting the development of the disease into its severer 
forms. "* 

It is not an unwarranted assertion that the seeds of 
every cholera epidemic which has appeared in this country 
have been brought hither in ships; therefore a careful 
watch should be kept over all vessels arriving from infected 
ports, or which would be likely to contain passengers who 
had been exposed to cholera. A suitable detention of 
ships and passengers should be enforced, and a thorough 
fumigation practised of personal clothing and baggage. 
With regard to the fumigation of ships and cargo, the pro- 
babilities, as drawn from evidence, are, that they do not 
nurture the infectious principle. Perhaps an exception 
should be made to a cargo or ship defiled by cholera dis- 
charges. 

* Report of Massachusetts Medical Society. Page 131. 



66 ASIATIC CHOLERA, 

It is true that some writers consider quarantine restric- 
tions as useless, judging from the instances in which the 
disease has crept through the closest barriers ; yet these 
instances do not overthrow the weight of those in which 
there is good evidence that quarantines have been effectual 
in preventing or delaying the introduction of cholera. 
This country is also, to a certain extent, isolated from 
those whence the disease has been previously brought, by 
a wide ocean ; and as the intercommunication is by means 
of ships, there is more to be hoped from quarantine deten- 
tions here, than in those countries which are in close 
proximity to infected districts, and where there is a con- 
stant intercommunication of individuals. 

At the same time, the fact that the most rigid quarantine 
has often been penetrated, should have its full force, and a 
reliance upon quarantine restriction as the sole means of 
preventing the entrance of cholera into any country is not 
justified by experience, and should certainly not supersede 
the thorough cleansing of all exposed ports and their 
vicinity. 

It is also essential that the quarantine regulations should 
be uniformly observed along the entire coast. 

The period of incubation which has been assigned to 
the disease by trustworthy observers, is a guide as to the 
length of time for which those held in quarantine should 
be detained. 

There are some very interesting observations which have 
been made upon this point. 



ASIATIC CHOLERA. 67 

The Genoese Medical Commission who were sent to 
Hungary and Vienna for the purpose of studying the 
phenomena of cholera, concluded that : — " Those who 
have absorbed the germs of the disease are generally 
attacked before the third, and always before the fourth 
day."* 

The British Medical Commission, who made similar 
observations in St. Petersburg, in 1831, after detailing a 
series of cases upon this point, state as their opinion: — 
" That in the above cases, in all of which the time inter- 
vening between an only exposure to infection, and the sub- 
sequent development of the disease, was most accurately 
marked, the period of incubation ranged between one and 
five days." 

Observations made in Berlin upon the same point, 
showed that of 171 cases, which happened in houses where 
one case had been reported, 159 occurred within five, and 
the remainder within eight days after the first. Prof. 
Memeyer,f after stating that some have placed the period 
of incubation at from eight to fourteen days, adds, that in 
a number of cases noticed by himself and Dr. Greifswald, 
the duration of this period was not less than thirty-six 
hours, and not more than three days. Dr. William Budd 
is of opinion that it seldom exceeds three days. Other 
observers (Madin, Huette, Rilliet, Hielmann, Weissbrod) 

* Report of Massachusetts Medical Society on Spasmodic Cholera. 
Boston: 1832. Page 129. 

f Pathologie und Therapie. Berlin: 1861. Page 636. 



68 ASIATIC CHOLERA. 

place it at from twelve hours to eight days. The disease 
appeared in Quebec three days after the arrival of the 
brig Carricks, and in Folly Island a day or two after the 
arrival of the Amelia; on Staten Island "immediately" 
after the arrival of the New York, and in New Orleans on 
the next day after the Swanton reached that city. 

These results indicate that the period of incubation 
occupies, in most cases, only a few days, and generally less 
than a week ; but there are instances in which a much 
longer time has apparently elapsed between exposure and 
the appearance of the disease. 

During an epidemic in the prison of Ebrach, in Bavaria, 
a released prisoner, who had been isolated in an adjacent 
building for fourteen days before being allowed his liberty, 
was seized with cholera on reaching his home at Kulmbach 
on the river Main. The homeward route from Ebrach did 
not lead through any infected district.* It is also stated 
that the first case of declared cholera at the Island of 
Mauritius, in 1819, did not occur before the fifteenth day 
from the arrival of the Topaz frigate. f Pettenkofer 
places the maximum of the incubation period at twenty- 
one days. 

Such instances seem to throw uncertainty upon the ques- 
tion as to the length of the period of incubation, but the 
facts connected with the appearance of the disease on the 

* Pettenkofer iiber die Verbreitung der Cholera. Page 135. 
f Report of Massachusetts Medical Society on Cholera. Page 
180. See also London Lancet for March, 1854. Page 236 



ASIATIC CHOLERA. 69 

New York and Swanton, may account for the long interval 
which has in some cases apparently elapsed between expo- 
sure to cholera and its development. As has been pre- 
viously stated, the disease did not show itself on the New 
York until sixteen, nor on the Swanton until twenty-seven 
days after sailing. Now there is evidence to make it 
highly probable that clothing defiled with decomposing 
cholera discharges is capable of communicating the dis- 
ease, and in the following instance the origin of an epidemic 
is traced to infection from the clothing of a cholera patient. 

In 1854 cholera was not known in the county of Bed- 
ford, when it broke out in the village of Kidgmount, and 
eleven cases occurred from first to last, all of which were 
fatal. On careful inquiry as to its origin, it was clearly 
ascertained, that the first case occurred in a man whose son 
had died of cholera in London a week or two before, and 
whose clothes were sent down to the country. The poor 
man unwrapped the bundle of clothes himself, was seized 
with the disease and died ; his case was the nucleus of the 
rest.* 

Hence, it is highly probable that emigrants or travellers 
from infected districts may have among their baggage 
defiled clothing, which, when brought out, would give rise 
to cholera. A supposition of contagion by such fomites 

* On Malaria and Miasmata, and their Influence in the Production 
of Typhus and Typhoid Fevers, Cholera and the Exanthemata. By 
Thomas Herbert Barker, M.D., F.R.S., etc. London: 1863. Page 
140. 



70 ASIATIC CHOLERA. 

would account for some, if not all, of those cases in which 
the period of incubation is unusually protracted. 

Consequently, although on excellent authority the maxi- 
mum period of incubation is placed at twenty-three days, 
so long an interval is rare, and may depend upon contagion 
by fomites. On the other hand, the length of this period 
of incubation is usually less than a week ; so that when the 
vexations and often useless delays consequent upon a long 
detention are considered, it is a question whether the 
uncertain immunity which it affords compensates for such 
impediments to commerce. A bundle of infected clothing 
may be passed through quarantine barriers, and produce 
an epidemic. Therefore, if thorough disinfection of per- 
sonal clothing and baggage is practised, and all exposed 
localities are carefully cleansed, so that if the disease enter 
it may find no soil to nourish it, it does not seem neces- 
sary to require a detention longer than ten days, including 
the passage, for healthy vessels from infected ports, or 
which contain passengers from infected districts; or for 
infected vessels, of more than ten days after the last case of 
cholera or acute diarrhoea. 

If the baggage of emigrants could be subjected to disin- 
fection or ventilation before the voyage, and great attention 
paid to the care of such emigrants on the passage, dur- 
ing the prevalence of cholera in Europe, the chances of 
importation of the disease to this country would be still 
further diminished. 

There is reason to believe that, other circumstances be- 



ASIATIC CHOLERA. 71 

ing equal, cholera is more likely to spread on land than on 
water. This might be inferred from the consideration, 
that the diarrhosa dejections of those on shipboard are cast 
into the water, while at the same time the vessel undergoes 
a kind of constant disinfection by means of the tarry exha- 
lations which are given out on every side. 

The limitation of the disease on the Atalanta favors this 
idea, and there are other facts which afford similar evi- 
dence. 

In the Report to the Minister of War of the British 
Sanitary Commission, sent to the seat of war in the East 
— 1855, 1856 — it is stated that during the prevalence of 
cholera in the ports of Varna and Balaklava, it was 
observed among the crews of the vessels stationed there, 
that those ships which put out to sea with an infected 
crew, lost the disease in from ten to sixteen days. The 
Britannia left Varna for the high sea, for the purpose of 
purification. The ship was heavily manned, and after the first 
week was deprived of so many soldiers and sailors as to be 
short-handed. In this emergency the commander request- 
ed the captain of another vessel, free from cholera, and 
which had not been in contact with any infected port, to 
take his sick men and at the same time send some of his 
own healthy crew to the Britannia. As a result, none of 
the crew which had left the clean vessel, or of those which 
remained on board of it, were seized with the disease. 

The "North America" arrived off New York in 1854 
with cholera on board, which had existed two weeks 



72 ASIATIC CHOLERA. 

before her arrival, and of which ten individuals had died. 
Seven cases were sent to the hospital on her arrival, and 
the following day all her passengers were landed. In three 
days 128 cases and thirty-two deaths occurred among 250 
passengers ; while the crew remained perfectly healthy, 
and no new cases could be traced to the vessel.* 

It is also worthy of note that, notwithstanding the 
extensive commerce which has long existed between India 
and England, the disease has always travelled to England 
by what might be termed an overland route. 

From the preceding it follows, that since there is no 
reasonable doubt of an immediate connexion between the 
presence of a ship infected with cholera at any port, and 
the origin and spread of disease in and beyond that port, 
it is very important that infected ships should be kept as 
far away from shore as is practicable, and intercommunica- 
tion prohibited. It may also be inferred that a quarantine 
will be more effectual if maintained upon the water than 
on the land ; if on the land, an island or a rocky foundation 
should, if possible, be selected for the accommodation of 
the sick, and if this be impracticable, then as dry a soil as 
can be found to answer the purpose. Where tents can 
be used they are preferable to hospital buildings. 

The well should be taken from the infected vessel, and 
detained in a separate vessel or structure built upon the 
water ; at the same time thorough ventilation and disinfec- 
tion should be practised on both vessels. 

* Philadelphia Med. & Surg. Reporter, Jan. 13th, 1866. 



ASIATIC CHOLERA. 73 

Hence cleanliness, ventilation, disinfection, the avoidance 
of moisture, a rigid isolation of the sick and their sur- 
roundings, together with immediate destruction of the 
specific powers of the cholera discharges by disinfectants, 
and the adoption of as strict a quarantine as is practicable, 
are, in general terms, the main preventive measures to be 
used for averting cholera. 



74 ASIATIC CHOLERA. 



CHAPTER IV. 

The severe symptoms of cholera are usually preceded by 
a painless diarrhoea. M. Marin states that premonitory 
diarrhoea was present in nine-tenths of the recent cases in 
Marseilles, and the replies received by the Cholera Com- 
mittee of the English Royal College of Physicians, 1848 
and 1849, "served to establish the frequency of a stage 
of diarrhoea, lasting from a few hours to several days."* 
In 200 cases reported by Briquet and Mignot there was 
premonitory diarrhoea in 143, and of these, the period 
within which the antecedent symptoms passed into those 
of a severe character, was in twenty-four cases one day, 
in twenty-one two, in fourteen three days, in three one 
hour, and in the rest from two to sixteen hours. Mr. 
Grainger and others have noticed that during certain 
epidemics individuals have suffered from frequent spas- 
modic pains in the bowels, and cramps in the calves of 
the legs, especially in those districts where the disease 
was severe, and these symptoms were not always accom- 
panied by diarrhoea. 

Yet, while diarrhoea precedes the characteristic symp- 

* In the late epidemic in Alexandria the disease was almost 
invariably preceded by premonitory symptoms. 



ASIATIC CHOLERA. 75 

toms in a majority of cases, it is not always present ; in 
some instances a few discharges are followed by collapse, 
and in others, very rare, a mortal coldness is present 
from the ontset. The manner in which the disease deve- 
lops is in many cases an index of its conrse. 

Dr. Gull states " that the diarrhoea premonitory of the 
severer symptoms of cholera was often feculent and bili- 
ous, and presented no characteristics whereby it could be 
certainly distinguished from other forms."* 

Dr. La Segue, in charge of the Hopital Necker in 
Paris, writes in the Archives Generales de Medecine of 
November, 1855, with regard to the diarrhoea of the 
recent epidemic, that it is liquid, serous, abundant, and 
more or less colored. The stools succeed each other 
every hour or two, and sometimes oftener. After the 
second or third they become whitish, like very thin paste, 
are voided without pain, and cause no sensations of burn- 
ing or tenesmus. In the interval there is an occasional 
rumbling of the intestines. The evacuations are not fol- 
lowed by that sensation of sinking so frequently asso- 
ciated with smaller discharges. When, after five or six 
stools, the nature of the matters passed is unchanged, 
and the excretions are no more serous or paler, it is a 
favorable symptom. The vomitings are sometimes green 
long after the discharges have become exclusively serous. 

* Eeport on Morbid Anatomy, etc., of Epidemic Cholera. By 
"William W. G-ull, M.D., Assistant-Physician to Guy's Hospital. 
Page 129. 



76 



ASIATIC CHOLERA. 



Eecent writers also state that diarrhoea and other prodro- 
mata did not make their appearance before the outbreak 
of the epidemic in Paris, but that soon after its commence- 
ment diarrhoea became very prevalent* This would seem 
to indicate that no epidemic influence preceded the arri- 
val of the pestilence, but that after its introduction an 
infection pervaded the air. 

Some observers have stated that diarrhoea is not the 
earliest symptom of cholera. Dr. Barrautf considers that 
a contracted and immovable pupil precedes all other mani- 
festations of the disease, and Dr. McNaughton, writing of 
cholera as it prevailed in Albany in 1832, says: — "The 
very first morbid change which I have been able to detect, 
was- in the tongue. This varies with a shade of white, so 
slight as scarcely to be perceptible, to that in which it is 
covered with a white, slimy coat, as thick as a sheet of 
paper. This coat may exist to a considerable degree with- 
out any loss of appetite or complaint on the part of the 
patient ; but when it is well marked, a slight check of per- 
spiration or irregularity of diet will bring on diarrhoea. "J 

M. Gibert states that the tongue, in bilious or inflamma- 
tory diarrhoea, is red, dry, and pointed ; in choleraic diar- 

* This was also observed with regard to the late epidemic in 
Alexandria. 

f British and Foreign Medico-Chirurgical Review, Oct. 1865. 
Page 416. 

J This symptom is mentioned in recent French journals as a 
new observation. 



ASIATIC CHOLERA. 17 

rhoea, broad, moist, white, and covered with a mucous 
paste.* 

The preliminary symptoms are succeeded, if unchecked, 
by what is usually termed an attack of cholera. Like 
the onsets of the sporadic disease, it often commences 
towards morning. The frequency of the attack at this time 
coincides with the reduction of nervous energy peculiar to 
this, the colder period of the twenty-four hours. 

Severe vomiting and purging, with tendency to collapse, 
are the marked features of this stage. Sometimes the 
entire contents of the intestine seem to be evacuated by 
the first discharge, which is ejected with force, and those 
succeeding consist of the characteristic rice-water stools. 
Chemical and microscopical analyses of these discharges 
have shown that the fluid part of them is the serum, 
deficient in albumen, but quite rich in salts, especially 
chloride of sodium, which has drained through the intes- 
tinal capillaries, and that the flocculi are composed of epi- 
thelial shreds, young cells, and detritus. Crystals of the 
ammoniaco-magnesian phosphates, undigested food, para- 
sites, vibriones, and spores, are also sometimes present as 
unessential and irregular components. Blood corpuscles 
are sometimes observed, and in such cases the stools give 
indications of a larger quantity of albumen. The matter 

* M. de Wouves has recently demonstrated that albumen is pre- 
sent in the urine of all cholera patients several days before the 
appearance of the severe symptoms. He regards this as a means 

of distinguishing between cholera and diarrhoea. 

5 



IS ASIATIC CHOLERA. 

vomited is generally similar to that discharged by the 
intestines. 

At the same time the thirst is insatiable, but draughts of 
water are rejected, there is languor and listlessness, and 
there are cramps, especially of the gastrocnemii.* These 
sometimes continue for a half minute or minute, and are 
often accompanied with intense pain. The debility 
increases; the pulse begins to contract; perspiration 
breaks out ; the voice becomes feeble or mute (vox cho- 
lerica), and the evacuations involuntary. The secretion of 
urine is suspended, or a very small quantity is passed of a 
low specific gravity (1006-1012), and albuminous; and 
while the cramps increase in intensity, there is added a 
sensation of oppressed respiration, which is one of the 
most distressing symptoms of cholera. 

In the meantime the countenance undergoes a great 
change. The eyes retreat in their sockets; the nose 
becomes pointed ; the cheeks sunken (facies cholerica) ; the 

* The cramps usually commence at the lower extremities, chiefly 
in the muscles of the calves, and extend upwards ; involving first 
the fingers and arms, then the thorax, neck, and abdomen, occasion- 
ally the loins. Cramp of the maxillary muscles is very rare. This 
spasm does not implicate alone the system of voluntary muscles, 
but extends to the involuntary. Among those organs endowed with 
smooth muscular fibre which have been noticed during life, the iris 
has frequently been found in a state of moderate spasm, the pupil 
being somewhat contracted and responding very slowly to light. 
(Buhl) Drasche on Cholera. Page 231. The pulse is usually about 
85, decreasing as the disease advances. 



ASIATIC CHOLERA. 79 

fingers wrinkled ; and if the skin is pinched in a fold it 
slowly recovers itself. The lips, extremities, and genitals 
are more or less cyanosed; sometimes the entire surface 
has a bluish or greyish hue. The carotids gradually cease 
to throb, the impulse of the heart and heart-sounds become 
imperceptible ; and with the irregularity of the circulation, 
and flow of an imperfectly oxygenated blood to the sur- 
face, the temperature of the body, especially of the exposed 
portions, is like that of a corpse (Stadium algidum). The 
sick seldom complain of headache, but frequently of tinni- 
tus, vertigo, or muscse volitantes. The intellect is not con- 
fused ; most patients are extremely indifferent to the threat- 
ened danger, but complain of cramps and a feeling of 
oppression. The skin preserves its sensibility, but its irri- 
tability is almost extinguished. The tongue is cold, gene- 
rally coated in the centre, and cleanat the tip and edges. 

The discharges cease some time before death, which is 
usually attended with complete apathy, and is not accom- 
panied by the death rattle, heard at the close of nearly all 
other diseases. 

The ancient aphorism, that heat is life and cold is death, 
does': not always apply to the corpses of cholera patients. 
There is very often an elevation of temperature after death, 
but this has also been occasionally observed* after asphyxia, 
yellow fever, peritonitis, and pneumonia. 

When death occurs at the height of the disease, the 
appearance of the body is very characteristic. The hands 
* Cruveilhier, Dowler, Briquet, and Mignot. 



80 ASTATIC CHOLERA. 

are clenched, the limbs drawn up, and the abdominal mus- 
cles contracted. Cadaveric rigidity comes on early, and 
lasts from twenty to forty hours. The countenance is 
greatly changed ; the eyes are sunken, and surrounded with 
wide blue rings ; the lids half closed ; the uncovered por- 
tion of the globe is like parchment ; the nose is pinched ; 
the lips bluish or dark brown ; the whole surface, in fact, 
cyanosed, a phenomenon most marked on the last phalanges 
and the toe and finger nails. The skin is wrinkled. 

On opening the body, the most striking appearances are 
the dryness of the subcutaneous cellular tissue, and the 
deep red hue of the muscles. " The blood contained in 
the cavities of the heart was, in the majority of cases, 
coagulated into a dark homogeneous mass, with fibrinous 
coagula extending into the large vessels. Virchow's state- 
ment, that these coagula contained a large number of color- 
less corpuscles, was confirmed by our own observations. 
The large venous trunks, and the veins of individual organs, 
were full of blood, whilst the arteries and capillaries were 
for the most part empty. This fulness of the veins was 
more marked in cases where death followed quickly upon 
the commencement of reaction after the cold stage."* The 
cerebral sinuses and meningeal veins are full of dark blood, 
the substance of the brain dry and firm. Several writersf 
mention the presence of a fulness of the exterior vessels of 

* Bernhardt and Leubuscher. (From Dr. Gull's Eeport.) 
f Payne on Cholera. Page 138. Report of Bell and Condie. 
Page 112. Drasche on Cholera. Page 250. 



ASIATIC CHOLERA. 81 

the spmal marrow, and Buhl observed the veins of the 
spinal marrow and the nerves proceeding from it (sammt- 
licher nervenstrange) to be swollen with blood. The vagus 
especially is surrounded with a dilated network of vessels at 
its entrance into the chest. The congestion of the sympa- 
thetic is rather confined to the ganglia, the solar plexus is 
often reddened throughout its entire substance, and ecchy- 
moses are sometimes observed.* There is no serum in the 
pericardium ; its inner surface has a viscid feel, and is often 
covered with ecchymoses. The muscular substance of the 
heart is firm, contracted, and of a deep red color. The 
pleurae, like the pericardium and other serous membranes, 
are covered with a viscid layer, and sometimes ecchymoses 
are observed in them. The lungs collapse suddenly on 
opening the thorax, apparently because the air finds no 
obstacle to its exit from the alveoli, through the dry and 
empty bronchial tubes. A section of the pulmonary tissue 
reveals no traces of congestion or oedema. 

The loose folds of the small intestines have a ruddy 
appearance on the exterior surface, while the large intes- 
tine retains its normal hue. In both large and small, are 
found, sometimes in large quantity, the peculiar rice-water 
discharges, as well as occasionally, medicines which have 
been administered but not absorbed.! The mucous mem- 

* Buhl. 

f Experiments have shown that absorption, although diminished 
during an attack of cholera, does not cease. Iodide of potassium 
administered during the algid stage, has been detected in the blood 
and urine. 



82 ASIATIC CHOLERA. 

brane of the small intestine is the seat of a high degree of 
congestion of minute vessels, most marked near the ileo- 
coecal valve, and gradually extending upwards. With this 
congestion, ecchymoses and haemorrhages upon the free 
surface of the membranes frequently coexist. Sometimes 
the small intestine is pale, neither ecchymosed nor con- 
gested. This is simply a post-mortem appearance, since 
the intestine is, in such cases, always full of fluid, and so 
large a quantity must have been poured out from congested, 
not empty vessels. The mucous membrane and entire 
intestinal wall are oedematous and swollen, and Peyer's 
patches and the solitary glands are filled with serum, or a 
firm exudation. As a result of this swelling of the folli- 
cles, the inner wall of the intestine seems fretted with, 
separate or aggregated, granular protuberances. Some- 
times a bursting of the follicles results in the formation of 
reticular patches. 

The most marked change in the intestine is the enor- 
mous separation of epithelium. The follicles are deprived 
of their protecting layer ; sometimes the epithelial cover- 
ing is raised by serum, and clings loosely to the fol- 
licles, but generally it is completely separated, and lies 
in shreds upon the inner surface of the intestinal wall, 
or forms the " rice-water" granules. It may be said, 
that the intestine of post-mortem examinations after death 
from cholera, is like a portion of integument from which 
the epidermis has been raised by a burn.* 

* Niemeyer. 



ASIATIC CHOLERA. 83 

Virchow* states that in women there was very com- 
monly " a menstrual ( ? ) condition of the ovaries, and of 
the lining membrane of the uterus ; in the ovaries, recent- 
ly-flattened follicles with effusion of blood ; and in the 
uterus, great swelling and hyperaemia of the mucous 
membrane, with enlargement of the uterine glands ; but 
apart from the menstrual period, it was not rare to find 
numerous extravasations under the peritoneal covering of 
the ovaries, giving them a mottled and purple aspect." 

No constant changes are observed in the large intes- 
tine. The liver is pale and of normal consistence ; the 
larger veins full of dark, viscid blood; the gall-bladder 
usually rilled with a thin, brownish or greenish bile ; 
the spleen presents .no constant changes. The kidneys, 
in the early periods of the disease, are normal, with the 
exception of a moderate venous hyperaemia. Sometimes 
whitish points may be seen, especially in the pyramids, 
and a microscopical examination reveals the urinary 
canals filled with turbid, swollen epithelium and fibrinous 
exudation. The mucous membrane of the urinary pas- 
sages is covered with viscid particles and shreds of epi- 
thelium ; the bladder contracted and generally empty. 

When death occurs in the stage of reaction, or during 
the typhoid period, cadaveric rigidity is less decided. The 
teeth and gums are covered with a dry and brownish 
exudation; the cyanosis is absent or less marked. The 
connective tissue is more moist ; the blood more fluid, 

* Med. Reform, No. 12 (from Dr. Gull's Report). 



84 ASIATIC CHOLERA. 

and of a lighter hue. The cerebral meninges are slightly 
injected ; in the meshes of the pia mater and lateral ven- 
tricles is an abundance of serum. The right side of the 
heart is generally distended ; the endocardium and lining 
membrane of the great vessels discolored. The lungs are 
more moist, and occasionally the seat of lobar or lobular 
pneumonic or hemorrhagic effusions. The external coat 
of the small intestine has lost its redness, and the contents 
are tinged with bile. In many cases there is a restoration 
of epithelium, but often a diphtheritic exudation, by which 
the mucous membrane is more or less transformed into 
dry and brownish scales. This diphtheritic exudation 
sometimes extends to the large intestines, and a similar 
deposit is found in the gall-bladder, vulva, and vagina. 
The liver and spleen have been found ruptured in rare 
cases, and the kidneys are full of blood ; showing in many, 
but not all instances, marks of acute croupous inflamma- 
tion. The bladder contains a variable amount of albumi- 
nous urine. 

Dr. Niemeyer, from whose work on Pathology and 
Therapeutics much of the previous portion of this chapter 
has been taken, gives it as his opinion that the characteris- 
tic changes in the post-mortem examinations of cholera 
patients, when death has occurred at the height of the 
disease, consist essentially of the terminations of an exten- 
sive catarrhal inflammation with shedding of epithelium 
and immense exudation into the intestine. 

Upon this point Dr. Gull writes: "Some observers 



ASIATIC CHOLERA. 85 

have referred the morbid* changes to a catarrhal con- 
dition, others have regarded the disease as a form of 
serous haemorrhage, and the Berlin pathologists, whose 
attention was particularly arrested by the occurrence of 
amorphous granular fibrin in and upon the affected sur- 
face of the mucous membrane, designate it a destructive 
diphtheritic inflammation. We believe that for the pre- 
sent such generalizations, however plausible, are of little 
value, and that we arrest inquiry by their adoption. * * * 
Cholera appears to consist of but one single series of 
actions, which may vary in intensity through every gra- 
dation, but throughout maintains the same character of 
passiveness." 

Mention should, however, be made of those theories, 
which, modified by different writers, claim that the pheno- 
mena of cholera are due primarily to the action of the 
specific poison upon the blood, and thus upon the sym- 
pathetic and spinal nerves, or on the sympathetic alone. 
Among these the views of Bell,* Greenhow,f John son, J 
and Chapman, are prominent. Dr. Bell is of opinion: 
" That the ordinary actions of the capillary circulation 
are put a stop to, or strangely altered, during the con- 
dition which we have termed spasm. That the spasm 

* C. W. Bell, M.D., RL S. Braithwaite's Retrospect, Yol. xvii., 

p. 95. 

f G-reenhow on Cholera, p. 21. 

% George Johnson, M.D., F.R.C.P., Professor of Medicine in 

Kings College. 

5* 



86 ASIATIC CHOLERA. 

lias a tendency to relax of itself in due time, and again 
to recur unless prevented by a change of action, induced 
either by natural or artificial means. And we have ob- 
served that in consequence of this action the blood is 
driven inwardly from the extreme capillaries into the 
great interior veins, leaving the extremities bloodless 
and chilly." 

Dr. Greenhow believed that the first impression of 
the efficient cause of cholera is made upon the minute 
ramifications of the sympathetic in the intestinal tube. 
According to Dr. Chapman, an extreme hypersemia of 
the spinal and sympathetic nervous centres is induced by 
the excessive heat of hot climates. Those nervous centres 
which govern the alimentary canal, become highly vitalized 
by this large supply of blood, and, as a consequence, the 
blood-vessels which nourish the intestines receive a larger 
supply of nervous influence from the vaso-motor nerve- 
centres, and contract more vigorously than natural. This 
contraction diminishes the supply of blood to the intes- 
tine, and renders it extremely irritable. For the same reason 
the reflex functions of the nervous centres are exalted, and 
" transmit their stimulating influence to the muscular 
fibres surrounding the bowels with a copiousness and in- 
tensity far surpassing the normal amount. Hence these 
circular muscles, enfeebled, but rendered peculiarly excita- 
ble, as previously explained, contract far more rapidly and 
vigorously than usual. The association of these three con- 
ditions — viz. enfeeblement of the muscular wall of the intes- 



ASIATIC CHOLERA. 87 

tine, preternatural exudation from its mucous membrane 
(caused by contraction of intestinal vessels), and excessive 
muscular activity, all dependent upon hyperemia of the 
nervous centres, constitutes the premonitory diarrhoea of 
cholera ; and, indeed, all those choleraic forms of intestinal 
flux known as the summer diarrhoea of temperate climates." 
Dr. Johnson, believing the great central fact of the disease 
to be, " that during the stage of collapse, the passage of 
blood from the right to the left side of the heart is in a 
greater or less degree impeded," places the contraction in 
the ultimate branches of the pulmonary artery. He says : 
" I believe the true explanation of the arrest of blood in the 
lungs to be this. The blood contains a poison, whose irritant 
action upon the muscular tissue is shown by the painful 
cramps which it occasions ; the blood thus poisoned excites 
contraction of the muscular walls of the minute pulmonary 
arteries, the effect of which is to diminish, and in fatal 
cases entirely to arrest, the flow of blood through the 
lungs." M. Marey, who has recently written upon the 
subject, also believes that the influence of the sympathetic 
system upon minute blood-vessels is the proximate cause 
of the choleraic diarrhoea."* 

How far do the symptoms of the disease and the patho- 
logical appearances sustain these theories ? 

* See Appendix, also Dr. G-ull's Eeport on the Pathology of Cho- 
lera, p. Ill ; also Payne on Cholera, New York, 1832, p. 110. Dr. 
G-eorge Johnson of Kings College. 



88 ASIATIC CHOLERA. 

Dr. Bell does not regard the collapse of cholera as the 
same condition to which the term collapse is usually ap- 
plied. He says : "If collapse from sinking or haemorrhage 
may be termed adynamic, we shall be forced to express that 
which occurs in cholera by the contradictory term dynamic ; 
that it is an active, not a passive condition of the capillary 
circulation." The blanched skin, resulting from haemor- 
rhage, is very different from the cyanosed skin of cholera ; 
and a proof that the coldness of the surface is due to a 
contraction of the capillaries, is the circumstance that 
when all action has ceased in death, the warmth com- 
mences where death commences — in the feet. The cholera 
is not a disease of the intestinal membrane alone, since 
changes similar to those which there are observed are met 
with in other organs, as the kidney and uterus. The force 
with which the vomitings and dejections are voided 
resemble the action of spasm, while the amount of collapse 
does not correspond constantly and necessarily to the dis- 
charges from the mucous membrane. The probability 
that the seat of the disease is in the nervous system, is 
increased by the fact that there is scarcely any other dis- 
ease in which such a complete and violent disturbance of 
all the functions is followed, in some instances, by such 
rapid recovery. 

There is not a paralysis of the sympathetic present dur- 
ing the cold stage of cholera, for experiments show that a 
section of that nerve is followed by a dilatation of the ves- 
sels and an afflux of blood, with an increase of tempera- 



ASIATIC CHOLERA. 89 

ture ;* and it is also most probable that if this nerve were 
paralysed, the lungs, instead of being anaemic, would be 
congested. The retention of the blood in the right side of 
the heart and pulmonary arteries seems to be due to spas- 
modic contraction of those arteries, and the engorgement 
of the lungs generally found when death occurs in the 
febrile stage after reaction may be supposed to result from 
a relaxation of the spasm. 

It is impossible to admit that part of Dr. Chapman's 
theory which claims that the excessive external heat in hot 
climates, or the direct rays of the sun upon the back, are 
the cause of cholera, since this hypothesis cannot be recon- 
ciled with the prevalence of the disease in winter or with 
its progressive character. Yet this is not an essential part 
of the theory, since hyperemia of the ganglia may result 
from other causes ; and if it be true that the cholera poison 
is an irritant, then the vaso-motor nerve fibres being irri- 
tated, could induce contraction of the blood-vessels by 
reflex action. f Dr. Gull writes, in reviewing the patholo- 
gical appearances of cholera : — " The principal phenomena 
which arrest attention are the oedematous state of the 
mucous membrane, and the more or less extensive patches 
of capillary and venous hypersemia and ecchymoses. 
These, together with the character and amount of the fluid 

* Physiology and Pathology of Nervous Centres, by C. E. Brown- 
Sequard, M.D., F.R.S. Page 140. 

f Brown-Sequard's Physiology and Pathology of the Nervous 
Centres. Page 146. 



90 ASIATIC CHOLERA. 

effused, demonstrate an important lesion of the circulation 
through the affected parts. How this is produced can at 
present be no further elucidated than by the hypothesis of 
a specific poison acting upon the ganglionic nervous cen- 
tres, or upon the mucous membrane. The former appears 
to us the more probable supposition, from being more in 
accordance with some other phenomena of the disease, as 
the profuse sweating and the sudden and severe collapse." 

The hyperaemic condition of the sympathetic ganglia 
which has been noticed by some, has not attracted the 
attention of others, but the fulness of the spinal veins is 
quite generally mentioned. 

Although it cannot be considered as proved that an 
arterial spasm or a hyperemia of the spinal and sympa- 
thetic nervous centres is the cause of the choleraic collapse, 
the former is rendered highly probable by the results of 
post-mortem examinations, especially the anaemic appear- 
ance of the lung ; and the fact that antispasmodic and 
relaxing remedies have been often found so useful in this 
disease, must have a certain influence in the same direction. 
With regard to Dr. Chapman's theory, while it is based 
upon scientific principles, it must be considered as under 
trial, and the results of a thorough test of it are awaited 
with much interest. 

If analogy may be used as a guide, the diarrhoea 
so common among those engaged in dissections, and 
which may be reasonably attributed to an effect produced 
upon the blood by exhalations from the cadaver which 



ASIATIC CHOLERA. 91 

enter the lungs, suggests the probability that the cholera 
poison may taint the blood by being inhaled. It is also 
probable that it may affect the system by being swal- 
lowed, as is seen from the late Dr. Snow's observations on 
water supply,* and by the following incident from the 
recent epidemic in Constantinople. 

In one instance the clothes, mattresses, etc., of the sick 
were washed at a fountain, and the water-pipe being unfor- 
tunately broken, the foul water communicated with the 
clean. In a single day sixty people died at Tatavola, which 
is a small portion of the city supplied by the infected 
stream, f 

Assuming that a spasm of the minute vessels is the cause 
of the collapse, the symptoms may be explained in the fol- 

* Dr. Snow gives the account of a well in Broad street into which 
a sewer had been percolating for several months during the year 
1864. Hundreds had drunk the water, and although cholera had 
been present in other parts of London, there had been no epidemic 
in St. James, the parish in which Broad street is situated. At last 
a case of cholera was imported by a person who used the privy that 
was connected by means of the cesspool with the well, whereupon 
more than 500 persons who received the water from that particular 
source were attacked within three days. (This may be explained 
by supposing that the person referred to brought the cholera poispn 
among individuals whose intestines were unusually irritable from 
the ingestion of water contaminated by ordinary excrementitious 
matter, and thus cholera was developed. It is not necessary to 
suppose that a specific poison caused a specific diarrhoea.) 

f Report of Medical Times and Gazette, Oct. 7, 1865. 



92 ASIATIC €HOLERA. 

lowing manner : — The blood repelled from the surface upon 
the internal veins forms ecchymoses and congestions in 
some organs, but its fluid portion is forced through the 
extreme ramifications of the mesenteric veins into the intes- 
tines, carrying with it the epithelium, and forming the rice- 
water discharges. As the blood is drained of its serum, it 
seeks fluid from other tissues, and effusions are sometimes 
thus absorbed, while the salivary and lachrymal secretions 
are diminished from a deficiency of water. At the same 
time thirst is induced. 

The prseeordial pain and nausea are due to the overload- 
ing of internal vessels,* and the oppressed respiration to 
defective pulmonary circulation. The supply of blood to the 
left side of the heart, as well as to its muscular tissue, is 
diminished, and hence results a contraction of the left cavi- 
ties and feeble cardiac impulse. If the circulation of the 
capillaries of the heart is checked, then, according to all 
physiological and pathological experience, a cardiac para- 
lysis is the inevitable result.f The small pulse is due 
to a diminished supply of blood in the artery, and perhaps 
in some degree to arterial spasm. The cyanosis is caused 
by the defective respiration and circulation of unaerated 
blood ; as a proof that the respiration is imperfect, 
appears the fact that cholera patients exhale only a 
small amount of carbonic acid. 

In studying the cause of the suppression of urine, it 

* Bell. t Johnson. 



ASIATIC CHOLERA. 93 

must be considered that the amount secreted depends 
chiefly upon the degree of lateral pressure in the glomeruli 
of the Malpighian corpuscles. It is also known that in 
those diseases of the heart and lungs which are accompa- 
nied by a deficiency of blood in the left side of the heart 
and arterial system, the urinary secretion is much dimi- 
nished ; hence, we cannot be surprised that in the cold 
stage of cholera, with the heart's action reduced to a mini- 
mum, and the pulse imperceptible even in the large arte- 
ries, the flow of urine ceases. The low temperature of the 
periphery of the body depends partly upon the diminished 
production of heat, less oxygen being taken into the sys- 
tem, and partly upon a deficient supply of warm blood to 
the skin, in consequence of cardiac debility.* 

In favorable cases the discharges become less frequent 
and smaller, and the stomach less irritable. Occasionally 
the cessation of the vomiting is followed by a troublesome 
hiccough. The circulation returns, the cyanosis gradually 
disappears, the countenance becomes more natural, and the 
disease passes from the cold stage into that of reaction. 
With the improvement in the circulation, the respiration 
becomes less embarrassed. Sometimes, after the symptoms 
of asphyxia have ceased, a few dejections follow, consisting 
of numerous masses of a normal hue and decidedly faecal 
odor. On the second or third day soft or consistent 'stools 
are observed, or there is constipation. The symptoms 
indicate regeneration of the intestinal epithelium. The 
* Memeyer. 



94 ASIATIC CHOLERA. 

first urine passed is almost without an exception albumi- 
nous.* 

In some cases in which reparation of the intestinal 
mucous membrane takes place less rapidly, the violent dis- 
charges cease, but a moderate diarrhoea continues, consist- 
ing of thin, fetid, and greenish excreta ; the pulse remains 
small, the temperature of the extremities low, and the 
patients are in much danger of dying from a fresh exacer- 
bation of the disease. An imperfect reaction is often fol- 
lowed by consecutive fever, and sometimes by tardy con- 
valescence. Again, reaction may be immoderate, the pulse 
becomes full and strong, the surface unusually warm, the 
eyes injected, and there are symptoms of a hyperemia of 
the brain and other organs. Such symptoms may be fol- 
lowed by consecutive fever or convalescence.! 

The following tabular comparison between consecutive 
fever (cholera typhoid) and ordinary uraemia, is from Dr. 
Gull's report on the pathology of cholera: — "Those 
(symptoms) characterizing the cholera typhoid, we have set 
down from the excellent treatise of Reinhardt and Leubu- 
scher on cholera in 1 849, and those depending upon ordi- 
nary uraemia are described mostly in Dr. Addison's paper 
of 1839:" 

\ Cholera Typhoid. 

1. Dull pain in the head. 

2. Dimness of sight, double vision. 

* Niemeyer. f Niemeyer. 



ASIATIC CHOLERA. 95 

3. Giddiness, drowsiness. 

4 Slight wandering of intellect. 

5. Spasms, tonic or clonic, of an epileptic form. 

6. Pupil normal. 

7. No paralysis. 

8. Pulse various, sometimes below the average ; commonly 
quickened or normal. 

9. Temperature of the skin at the beginning slightly raised ; 
in further course normal, with extremities cool. 

10. Tongue moist and furred, and later in the disease, dry 
t 

and brown. 

11. Vomiting, which ceased when the cerebral symptoms 
became more intense. Evacuations feculent ; their consistence 
various. 

12. Frequent excitement and irregular rhythm of the respira- 
tory movements, with stertor. 

13. Urine suppressed or small in quantity, and albuminous. 

Ordinary Urcemia. 

(4) "Dulness of intellect, sluggishness of manner. (3) 
Drowsiness preceding coma, and more or less stertor, with 
or without (5) convulsions." These symptoms being l * very 
frequently preceded by giddiness, (2) dimness of sight, and (1) 
pain in the head." There is (8) " a quiet pulse, a contracted, 
or undilated, or (6) obedient pupil, and the (7) absence of 
paralysis." 

9. Temperature of the skin natural. 

10. Tongue at first natural, afterwards dry and brown. 

11. Vomiting an early symptom, ceasing when the brain 
becomes oppressed. 



96 ASIATIC CHOLERA. 

12. Respiration frequently with stertor. Rhythm irregular 
and quickened. 

13. Urine albuminous. 

"The communications received by the college,* show 
that the symptoms of the consecutive fever are most fre- 
quently referable to the defect in the urinary secretion." 
Other observers confirm this testimony.! With regard to 
a second attack of cholera, Dr. Drasche writes that he 
found only five cases out of 1630 in which the disease 
appeared a second time in the same person. 

The disturbances of the digestive organs are among the 
most frequent sequelae of the disease. Sometimes a chronic 
diarrhoea, with vomiting and loss of appetite, ensues, accom- 
panied with peculiar sensitiveness in the epigastric region, 
or there is a protracted indigestion. 

The urinary apparatus is also liable to derangement. 
The urine is very abundant in many cases of convales- 
cence, and the appearances of vesical catarrh are also pre- 
sent. Dr. Drasche has never seen Morbus Brightii, or its 
specific signs in the urine, remaining consecutively to a 
recovery from cholera. It is said that epileptic attacks are 
among the sequelae of the disease. 

Cholera is fatal in proportion to the algid symptoms. 
Complete suppression of urine or tenesmus with an empty 

* Royal College of Physicians. 

f "The typhoid symptoms result from retained urinary consti- 
tuents; perhaps other products of decomposition." Drasche on 
Cholera. Page 282. 



ASIATIC CHOLERA. 97 

bladder ; great anxiety and unrest ; the appearance of par- 
tial cold and clammy sweat upon the extremities, forehead, 
or face, are unfavorable symptoms. 

Statistics differ much as to the frequency of the cholera 
exanthem, but seem to show that it is most frequently 
observed in the latter half of the epidemic. " It appears to 
be nearly allied to urticaria febrilis. * * * Since 
similar eruptions are known to be intimately dependent 
upon disorders of the intestinal mucous membrane, and 
these are, after an attach of cholera, frequent, we cannot 
but refer it in a general way to such a source, admitting as 
we must in ordinary urticaria and erythema, that the indi- 
vidual peculiarities which determine its presence are not 
obvious, 'f Some have regarded it as due to sinapisms 
and frictions employed during the cold stage. 

The medium duration of 3600 cases of cholera observed 
during the epidemic of 1854 in London, was 5*9 days ; of 
1744 fatal cases, 2*68 days ; of the 1856 cases of recovery, 
9*06 days. The duration of 9590 cases returned in the 
register of deaths closely corresponded, being 2*39 days.f 
Of 4907 deaths during the first epidemic in Paris, 204 
occurred in from one to six hours, 1007 in from six to 
eighteen hours, and 1173 in from eighteen to twenty-four 
hours. 

Deductions made from 72,110 deaths from cholera and 

* Dr. Chill's Report. Page 145. 

t Report of General Board of Health. See Reviews, Med. Times 
and Gazette, Oct. 6th, 1855. Page 350. 



98 ASIATIC CHOLERA. 

diarrhoea which occurred in England in 1849, show that 
although the epidemic was unusually fatal in infancy and 
old age, it was less so in proportion to the mean percentage 
of mortality at those ages than during the vigorous periods 
of life.* The mortality is about the same in both sexes. 

It might naturally be inferred that in a disease so modi- 
fied by local conditions, the rate of mortality would be 
somewhat variable. It is affected by the mildness or 
severity of each epidemic, by conditions of soil and cli- 
mate, and cleanliness ; as occurring in hospitals or private 
practice. An observation of the death-rate in a large num- 
ber of epidemics, shows a mortality of about fifty per cent.,f 
but these numbers are only an approximation to the truth. 
The practical inference is, that since the mortality is 
increased by local conditions, it may be diminished in pro- 
portion as the influence of those conditions is rendered 
inoperative by hygienic measures. 

* Dr. Gull's Report on Cholera. Page 148 et seq. 
f Dr. Drasche. 



ASIATIC CHOLERA. 99 



CHAPTER V. 

An examination of the therapeutics of cholera, as observed 
in the writings of many authors, renders it apparent that a 
large number of cases will recover under almost any kind 
of treatment. 

M. Velpeau is of opinion " that it is not impossible that 
a notable number of cholera patients recover without reme- 
dies or specifics, and in spite of them ; and the proof is that 
in all epidemics, in the violent one of 1832, as well as 
those of 1849 and 1854, more than one-half of the cholera 
patients have recovered ; have recovered by methods of 
treatment most opposed and various."* 

At the same time the tendency to search for a specific 
cure, sometimes to the neglect of rest, warmth, and other 
similar powerful aids to recovery in all diseases, is obvious ; 
while it also becomes evident that remedies are successful 
in proportion as they are administered at an early period of 
the malady, and that medicines cannot be judged by the 
success which often follows their use during the decline of 
an epidemic. f 

* EAbeiUe Medicate, Nov. 13, 1865. 

t There is a great need of accurate statistical information as to 
the effects of remedies in cholera. It is especially necessary in this 
disease, since so many remedial agents and measures have been 



100 ASIATIC CHOLERA. 

In the preliminary stage it is generally admitted that 
the results of treatment are very satisfactory. This is evi- 
dent from the success which has followed house to house 
visitations. It may also be inferred, that since the 
object of those visitations has been to stop the prelimi- 
nary diarrhoea, and there is nothing to show that the large 
number of patients who have been cured of it, even in 
the earliest stage (when, if it be true that the diarrhoea is 
an effort of nature to throw off a morbid poison, it would 
be natural to suppose that the noxious agent was present in 
full force), have suffered from the effects of a retained poi- 
son ; therefore the diarrhoea is not conservative, but should 
be checked as soon as possible. Another reason for arrest- 
ing the diarrhoea arises from the fact that during the pre- 
valence of a cholera epidemic the number of deaths from 
diarrhoea bears a large proportion to those from cholera ; 
while it is known that at such times a looseness of the 
bowels is often speedily followed by vomiting, purging, and 

warmly advocated. Extensive experience is also deprived of a part 
of its value when unsupported by statistics ; for those who have 
had ample opportunities of studying the disease, differ as to the 
choice and influence of remedies. In forming an estimate of the 
action of medicinal agents in this malady, it is very important to 
know the surroundings of the patient, the period of the epidemic, 
and stage of the disease when the dose was given, the amount of 
the dose, the method of administration, and the results of treat- 
ment. 

It is stated that nine-tenths of those attacked in the outbreak of 
an epidemic die. 



ASIATIC CHOLERA. 101 

all the symptoms of a choleraic attack. The same consi- 
derations apply to the treatment of cholera by laxatives, 
and here the case is stronger ; for the operation of a purga- 
tive has, in some cases, been simultaneous with the first 
stage of an attack of cholera which has terminated fatally.* 
Still another reason for checking the watery discharges of a 
choleraic diarrhoea is, that it is the tendency of the disease 
to deprive the blood of its water, and thus interfere to a 
great degree with its natural and therefore requisite com- 
position. 

Consequently, it may be considered that the indication 
with reference to the preliminary diarrhoea is to stop the 
discharges. 

The best authorities are in favor of absolute rest in bed 
from the commencement of the diarrhoea, warmth to the 
surface by means of heated flannels, or bricks, or bottles of 

* Two very striking cases have been observed by M. Chauffard 
in the clinical service of La Charite, where he was temporarily in 
charge. One was a woman admitted for severe bronchitis, in whom 
the administration of a saline purgative given for constipation was 
followed by violent purging, coldness, and change of countenance. 
She was fortunately rescued after the use of opium in large doses, 
and the tris-nitrate of bismuth; the second, more unfortunate, was 
a convalescent from articular rheumatism, who having shown some 
indications of intestinal derangement, was placed upon the use of 
Seidlitz water. Its employment produced excessive and uncontrol- 
lable diarrhoea, soon followed by the outburst of all the symptoms of 
confirmed cholera, which was rapidly fatal. — {Bulletin Gen. de Thera- 

peutique, Nov. 30, 1865. Pao-e 4? 3.) 

6 



102 ASIATIC CHOLERA. 

warm water, and sometimes a sinapism to the epigastric 
region. Some consider abstinence from food as essential, 
and others are in favor of giving small quantities of nutri- 
ment, such as iced beef-tea, at short intervals during the 
illness. Fresh air is also very essential. 

The remedies which have been used in this, as in every 
period of cholera, are innumerable, but those which have 
acquired the greatest general confidence for the preliminary 
stage, contain a certain amount of opium ; this, in small 
doses, is the medicine which may be said to rank first 
among the curative agents of the preliminary diarrhoea. It 
is used in powder or*tincture, or in combination with cam- 
phor, as the camphorated tincture; it is also given with 
brandy. Large doses of opium are believed to be less effi- 
cacious than small ones, and probably tend to induce con- 
secutive fever. 

The effects of small doses of opium are thus described 
iu the U. S, Dispensatory : — " Taken by a healthy person 
in a moderate dose,* it increases the force, fulness, and 
frequency of the pulse, augments the temperature of the 
skin, and other effects, very important in a remedial point 
of view, are also experienced. All the secretions, with the 
exception of that from the skin, are either suspended or 
diminished ; the peristaltic motion of the bowels is les- 
sened, pain and inordinate muscular contraction, if present, 



* In catarrh or diarrhoea, we often prescribe not more than one- 
fourth or one-third of a grain. — U. S. Disp. 



ASIATIC CHOLERA. 103 

are allayed, and general nervous irritation is composed, if 
not entirely relieved." 

This quotation is introduced for the purpose of present- 
ing the effects of moderate doses of opium in detail, since 
this medicine is sometimes given without a clear view of 
the indications which, it fulfils. 

Somewhat similar in its effects to opium is chloro- 
form when administered internally, although it has more 
of an antispasmodic action. Dr. A. P. Merrill, of New 
York, claims that it is par excellence a remedy for con- 
gestion, "whatever may be its cause and character."* 
Dr. Henry Hartshorn e, of Philadelphia, thus writes of this 
medicine, in the American Journal of Medical Sciences :f — 
" Experience has shown that, taken into the stomach, it is 
as totally free from danger as any other drug ; and its em- 
ployment is destined to be yet much more widely extended ; 
a fluid-drachm of chloroform taken by the stomach is not 
more than equal, in soporific effect, to thirty or thirty-five 
drops of laudanum. In doses of fifty to seventy-five 
drops (about fifteen minims), I have given it every half 
hour for several hours together. It differs from the opiate 
preparations in the promptness of its hypnotic action, the 
much shorter period of its duration, a less degree of cere- 
bral oppression, and the absence of all stimulus to the cir- 
culation. It might be called a l diffusible narcotic,' com- 
paring in this respect with opium as ammonia does with 

* New York Medical Journal, Oct., 1865. Page 6. 
f January, 1854. Page 113. 



104 ASIATIC CHOLERA. 

alcohol. To produce much effect with it, repeated doses 
at short intervals will be necessary. Its pungent property 
causes it to require plentiful dilution, which is, of course, 
facilitated by the action of some demulcent. Perhaps the 
orgeat syrup is the best. Every fluid-drachm of chloroform 
should have at least two fluid-ounces of water with it when 
taken ; and it will need, if in ordinary gum mucilage, con- 
siderable agitation to re-suspend the particles immediately 
before swallowing. When taken in aqueous mixture alone, 
however, unless in very small doses, it produces nausea with 
some persons. This is entirely prevented by the addition 
of a strong aromatic, or still better, by giving the chloro- 
form in aromatic tincture. From the ready solution and 
kindred action of camphor with chloroform, their combina- 
tion has become a very common one. For many purposes, 
however, a still better preparation is a sort of chloroform 
paregoric, or compound tincture of chloroform, e.g. fy. 
Chloroform, f 3 ij ; sp. camph. et tinct. opii, aa f 3 iss : ol. 
cinnamom., gtt. viij ; alcohol, f3iij. M. et fiat tinctura. 
Dose, from five to thirty minims, or more, as required. 

" The most admirable effects have been witnessed from 
the administration of chloroform, as above combined, in 
malignant cholera. In the summer of 1849, my attention 
was first called to it while attending a very severe case of 
cholera with the late Prof. W. E. Horner. The prompt 
and signal restoration accomplished in that case, from a 
state of collapse, was evidently due to the exhibition by 
Prof. Horner, every five minutes, of a few drops of a com- 



ASIATIC CHOLERA. 105 

bination of chloroform, oil of camphor, and laudanum, with, 
ice, and warm frictions externally. The writer's conviction 
was very strong that the short interval between the doses 
was an important item in the treatment ; and in pursuing 
the same plan in a number of subsequent cases, several of 
which were of the most alarming violence, an extremely 
gratifying success was obtained. The opinion has thus 
been formed, that no other plan of treatment gives so much 
promise in the management of malignant cholera as a com- 
bination of powerful yet mild antispasmodics, such as 
above described, with ice internally, and persisting external 
stimulation." 

A part of this extract belongs to subsequent pages of 
this work, but as the train of thought is more clearly fol- 
lowed by reading it in connexion, it seems better to intro- 
duce the whole of it in this place. It will be noticed that 
the chloroform was given in combination, and that opium 
was one of the ingredients ; perhaps a union of these two 
agents, or of these with stimulants, is more efficient than 
either alone. In Braithwaite's Retrospect, for January, 
1866, chloroform is also recommended as a "valuable 
remedy in the earliest stages of cholera," and a number of 
cases are given in which it seems to have been very useful. 
The theory that vascular spasm is an essential element of 
the first stage of cholera receives some confirmation from 
the effects which have followed the use of these and other 
antispasmodic remedies. 

Mention should also be made of dilute sulphuric acid as 



106 ASIATIC CHOLERA. 

a remedy in the premonitory diarrhoea of cholera, since it 
has apparently been found of great service. In 1851 
Mr. Buxton of London called attention to its great effi- 
cacy in several forms of diarrhoea, especially choleraic 
diarrhoea. In October, 1853, Dr. W. H. Fuller, of St. 
George's Hospital, published a paper in the London Medi- 
cal Times and Gazette, highly recommending it from his 
own experience and that of his friends, in more than ninety 
cases without a failure. It was given in doses of half 
a fluid drachm diluted with water, every twenty minutes 
in ordinary cases, every quarter of an hour in severe cases. 
The vomiting, purging, and cramps usually ceased after 
the third or fourth dose. It is not a suitable remedy in 
bilious diarrhoea. 

Eecently, M. Jules Worms, Medecin-en-chef of the 
Military Hospital of Gros-Caillou, has also endorsed this 
medicine in very high terms. 

His practice is as follows : — 

"In cases of premonitory diarrhoea, and according to 
their greater or less severity, I add three, four, or at most 
five grammes, by weight, of concentrated sulphuric acid in 
a kilogramme of decoction of salep, Sweetened to 150 
grammes. 

" The patient takes a glassful of this lemonade from hour 
to hour, rinsing the mouth two or three times after its 
use ; it is seldom that four glasses are necessary. At the 
same time I allow the use of white wine and champagne, 
but expressly proscribe beer, brandy, or the alkaline 



ASIATIC CHOLERA. 



107 



mineral waters, during the continuance of the epi- 
demic."* 

The following statement, introduced without comment, is 
based on 800 cases of cholera treated in the provinces, 
throughout England and Scotland in 1854, and, represents 
the order of percentage of failure after the use of various 
remedies in premonitory diarrhoea : — f 



Catechu, kino, etc., 

Salines, . 

Eliminants, 

Calomel, . 

Calomel and opium, 

Stimulants, 

Chalk and opium, 

Acetate of lead and opium, 

Opium, 

Chalk mixture, 

Sulphuric acid and opium, 

Dr. Lasegue, in his recent clinical study of the epi- 
demic in Paris, says, with regard to accidental diarrhoeas, 
such as are produced by indigestion or food taken at 



Per cent. 


Or, including 

deaths 

as failures. 


59-0 


59-0 


41-9 


41-9 


25-0 


250 


24-0 


25-3 


189 


22-0 


16-0 


21-8 


138 


171 


11-2 


14-0 


8-6 


13-7 


3-6 


5-0 


2-6 


4.0 



* Archives Generates de Medecine, November, 1865, page 616. A 
gramme = about 15 J- grains Troy measure. A Kilogramme = 2 
lbs. 8 oz. i 3 • 14 grains Troy measure. 

f General Board of Health. Report on the Results of the Differ- 
ent Methods of Treatment, by the Treatment Committee of the 
Medical Council, 1855. 



108 ASIATIC CHOLERA. 

improper hours : — " In such cases the stools are feculent, 
dark, of a characteristic smell, and the diarrhoea yields 
without being succeeded by any special symptoms. The 
patients, either from fear or ignorance, have hastily re- 
sorted to laudanum, stimulants, or bismuth. The disease 
checked without being cured, there follows an increased 
discomfort, thirst, slight febrile reaction, and especially 
colics, which are combated by the same means. 

" Without being in favor of emetico-cathartics, at the 
commencement of decided cholera, I have never observed 
anything but benefit from their use, in those affections 
which did not partake in any degree of the epidemic influ- 
ence. I am convinced that by suppressing such symptoms 
which tend to become protracted, the predisposition to 
contract the reigning malady is rather diminished than 
increased."* 

Yet such cases as those observed by M. Chauffard at La 
Charite, to which reference has been made, show that the 
action of purgatives is very uncertain during the prevalence 
of cholera, and that great caution is necessary in their use. 

The treatment of impending and complete collapse gives 
very unsatisfactory results. In this condition " the life of 
all the blood is touched corruptibly," it is a sluggish and 
thickened fluid, poisoned by retained excretions, and con- 
taining an abnormal number of white corpuscles. At the 
same time absorption, though not suspended, is very imper- 

* Archives Generates de Medecine, Nov., 1865. 



ASIATIC CHOLERA. 109 

fectly performed; and remedies, though sometimes followed 
by a happy issue, are very, very often, inefficacious. 

In the report of Drs. Baly and Gull, to which reference 
has been previously made, are given the results of the treat- 
ment of cholera in this stage, as obtained from the replies 
of English physicians to questions upon this subject. A 
selection from this portion of that deeply interesting and 
masterly work, together with outlines of treatment in the 
different stages of cholera, condensed from a few recent 
writings, will form the remainder of this chapter. 

The treatment by small and repeated (about five grains 
every half hour) doses of calomel, gave the following 
results : — 

Of 365 cases there were 187 deaths, and 178 recoveries. 

Of 725 cases of complete collapse treated by Dr. Ayre 
on a similar plan, 365 died. Other statistics on the same 
point are as follows : — 

Of 69 cases, 35 died. 

" 30 " 18 recovered. 

« 19 u u « 8 u 

11 30 " 18 " 12 " 

u 7 u 31 u 39 u 

u n u 5 u 6 U 

As to the treatment by calomel, opium, and stimulants, 
it was found that opium was a dangerous medicine in col- 
lapse, and the same was true of stimulants. Perchloride 
of carbon, and camphor and chloroform, produced reaction, 
but it was not permanent. 



110 ASIATIC CHOLERA. 

" The results of this treatment were unfavorable, and not 
altogether so indifferent as when calomel was given by 
itself. Although opium and diffusible stimuli, brandy, 
camphor, and ammonia, were useful at an early stage of the 
disease, as collapse set in they not only failed to produce 
any favorable results, but often aggravated the symptoms. 
It seems well ascertained, that opium in large doses was at 
this period injurious, by increasing the cerebral oppression 
and embarrassing the system during reaction. It was pro- 
bably less and less applicable as the disease advanced to its 
characteristic development. Stimuli, especially the various 
preparations of alcohol, did not act as restoratives in col- 
lapse, but often increased the irritability of the stomach 
and added to the sense of oppression in the prsecor- 
dia." 

Dr. Burrows gives twenty-one cases treated from July 
\§ih to 2 5 th y 1849 : twelve were males and two females. 
All the patients had a warm bath, and five grains of calomel 
with one of opium were given every two to four hours. 
According to urgency of symptoms, ammonia, brandy, 
wine, and chloroform were given, and cold water and ice 
freely. 



Ages. 


Of these there were 


Deaths. 


Eecoveries. 


Under 20, . 


) 3 were not in 
) 3 in slight 


collapse. 






3 
3 


From 20 to 40, 


.12 11 in marked 


a 


7 


4 


Over 40, . . 


. 3 4 in extreme 


a 


4 






In fourteen cases treated on the same plan from Sept. 



ASIATIC CHOLERA. Ill 

20th to Sept. 25th, seven males and seven females, the 
result was as follows : — 

Ages. Of these there were Deaths. Recoveries. 

Under 20, . . 3 4 were not in collapse, 6 4 

From 20 to 40, . 9 2 in slight " 6 2 

Over 40, ... 2 8 in marked " but 

symptoms not extreme 2 6 

Dr. Shapter, of Exeter, gives sixty-eight cases, of which 
forty-one recovered and twenty-seven died. He adds : — 

"This combination (calomel and opium) appears to 
avert death more successfully than mercury by itself; 
nevertheless, those cases which recover, whether from inci- 
pient or complete collapse, are, if the use of opium be long 
persevered in, more likely to pass into consecutive fever 
than if no opium be given." 

Sixteen cases were treated by Dr. Bashan with calomel 
and opium, brandy, ammonia, chloroform, sinapisms, and 
the warm bath ; in some cases enemata of acetate of lead 
were used. There were two recoveries and fourteen 
deaths, eleven were in marked collapse. Of other cases 
treated on a similar plan, in 

Deaths. Recoveries. 
27 cases of collapse there were 16 11 

4 " the incipient stage, there were 15 6 

Dr. Shapter reported forty cases treated with stimulants : 
twenty-one died, nineteen recovered. 

Dr. Blackall reported twenty-eight cases, males ; five 



112 ASIATIC CHOLERA. 

were treated with brandy and laudanum ; ten with camphor, 
chloroform, and ammonia ; seven with chloroform and 
brandy ; three with turpentine ; three with camphor alone. 



Ages. Of these there were Deaths. Recoveries. 

2 were not in collapse, 2 

6 in slight " 15 

From 20 to 40, .11 . 7 in marked " 6 1 

Over 40,. . . 7 13 in severe " 12 1 



Under 20, . . 10 1 



Dr. Barclay's report of cases in St. George's Hospital : — 

Stimulants were administered in large quantities in five 
cases, three recovered; in moderate quantity in fifteen 
cases, four recovered. They were altogether withheld in 
four cases, of these two recovered. In no case in which 
collapse was complete did stimulants restore the circulation. 

Mr. Vines, of Reading, says : — " Chloroform was tried but 
its effects were evanescent." 

Mr. Butcher, of Ware, in a letter to Dr. Davies, speaks 
in high terms of the value of chloroform for arresting the 
early symptoms of cholera, viz. vomiting and cramps. It 
does not seem to have been successful in rallying patients 
under impending collapse, nor in arresting the onward 
course of the disease. Four cases of urgent cholera were 
treated by Mr. Butcher with stimulants, warm bath, and 
chloroform ; two died and two recovered. 

Dr. Barclay's report from St. George's Hospital: — 
Chloroform was administered in combination with camphor 
in three cases, two of which proved fatal. In one case it 
was employed in the premonitory stage every half hour 



ASIATIC CHOLERA. 113 

for several hours, and was abandoned only when decided 
symptoms of cholera occurred. It was also administered 
near the close of another fatal case without apparent benefit. 

Dr. Blackall says :— " Seven cases were treated with 
chloroform, one of these was in articulo mortis, and there- 
fore not to be considered. Of four in collapse, three died 
and one recovered ; of two in approaching collapse, both 
recovered." 

" Cold water was generally preferred, and good results 
were often observed when it was taken freely in repeated 
and copious draughts, although it excited vomiting. 

"Dr. Arnot administered a mixture of ice and salt in 
two cases, both recovered." 

Salines, when administered at an early period and in a 
concentrated form, seemed to favor the discharges. 

Dr. Burton reported twenty cases treated mainly by 
salines, fifteen were males and five females : 



1 
11 
3 
4 
1 



Of 7 years there was 

From 20 to 40 years, there were 

11 40 to 50 " 

" 60 to 80 " " 

Of unknown age, there was 



Nine were in the premonitory stage, four in approaching 
collapse, seven in collapse when the treatment commenced. 
The saline mixture given was sodae sesquicarb. 3 i. ; sodii 
chloridi 3 i. ; potass, chlor., gr. viij. ; aquae Oss. ; occasion- 
ally the sulphate of magnesia was given, largely diluted. 



114 ASIATIC CHOLERA. 

There were six recoveries and fourteen deaths ; three of the 
six recoveries were mild cases. 

Dr. Hawkins reported that of thirty-seven cases in Mid- 
dlesex Hospital treated by mercurials and salines, seventeen 
recovered and twenty died. 

The report states with regard to the effect of emetics : — 
" The amount of evidence received in the communications 
is too small to admit of any definite conclusion as to the 
conditions under which these remedies are applicable, but 
the general deduction is, that in the early stages they were 
sometimes of use, and in collapse the effects were equivo- 
cal." As to bleeding, it is stated that " its general admissi- 
bility is to be inferred from its almost entire disuse." Heat 
was found useful in the early stage ; the wet sheet favored 
reaction in mild cases, but when the disease was severe it 
proved useless or injurious. Frictions, chloroform lini- 
ments, and warm fomentations relieved the cramps, and in 
the milder cases stimulating epithems of mustard or tur- 
pentine were of some use in relieving local symptoms and 
obviating nervous depression. 

No permanently favorable effect was produced by oxygen 
or galvanism.* " The results of saline injections into the 
veins are, as in 1831 and 1832, generally unfavorable. Its 
value cannot, however, be determined by statistics collected 
from various sources. The operation in all its details is a 

* M. Yigla, who has recently experimented with inhalations of 
oxygen on a grand scale in Paris, states that he has not had a suc- 
cessful case. — Bull. Gen. de Therap.j Nov. 30, 1865. 



ASIATIC CHOLERA. 115 

delicate one, and requires not only a careful discrimination 
of the cases to which it is applicable, but also an exact at- 
tention to the physical characters and composition of the 
fluid to be injected, and other collateral circumstances. 
Until these points receive greater elucidation, the results 
obtained can form no sound basis for an opinion respecting 
its merits. * * * * In an adult not more than from 
forty to sixty ounces, at the rate of from two to three 
ounces per minute, should be injected without intermission. 
The operation may be repeated according to the necessities 
of the cases, and this is for the most part to be preferred 
to throwing in double the quantity at once. Cases have 
terminated successfully where such an amount of injection 
has been repeated five or six times." 

The salt to be used for injections into the veins should 
be composed nearly in the following proportions of the 
various ingredients : — 

Chloride of sodium, . . .60 parts by weight. 

" potassium, 6 " " 

Phosphate of soda, 1 3 " " 

Carbonate of soda, ... 20 a " 

140 grains of this are to be dissolved in forty ounces of 
distilled water. 

"As to the temperature, it has been found that 110° 
Fah. is not injurious." The addition of a small quantity of 
alcohol to the saline injections was tried in 1832 and 
repeated with success in 1848. 



116 ASIATIC CHOLERA. 

M. Worms says of his treatment in collapse : — 

" The patient is left in absolute repose. Frictions are 
not used unless required to ease the cramps ; every half 
hour a glass of lemonade (sulphuric acid, syrup, and water) 
of 5 to 10 grammes of acid to a litre is given, and advan- 
tage is taken of the instant after the vomiting, for its 
administration. Wine and ice are allowed a discretion. 

" I think it worthy of notice that the lemonade wfeich is 
very effectual in controlling the alvine evacuations, produces 
a different action upon the vomitings, which are prolonged 
in duration and frequency. But this prolongation has a 
favorable influence, and is generally the indication of a 
happy termination." 

It will be observed that the acid acts as an emetic, and 
M. Worms states that the vomiting has a favorable influ- 
ence upon the course of the disease. This medicine is also 
antiseptic. 

In the Gazette Hebdomadaire of December 8th, 1865, 
Dr. Parrot gives an analysis of sixty-three cases of cholera, 
treated in La Charite Hospital. The treatment consisted in 
the administration of from four to eight grammes* of chlo- 
roform daily in severe cases, and from two to four in mild 
ones. The vehicle was water 100 grammes and syrup of 
quinine twenty grammes. This mixture was given in tea, 
a tablespoonful every half hour; at the same time iced 
beef-tea was given very frequently in small quantities. 
Warmth was applied to the skin, and dry and stimulating 

* A gramme = about 15£ grains, Troy weight. 



ASIATIC CHOLERA. 117 

frictions were used. Chloroform given in this way, calmed 
the anxiety and epigastric pain, and seemed to diminish the 
frequency of the vomitings, which were also less pain- 
ful. 

Of the sixty-three patients, fifty-three were grave cases, five 
moderate, and five mild. There were twenty-five recoveries 
and thirty-eight deaths, but three died immediately after 
admission, and two at the close of two hours. Two young 
women in the third stage of phthisis pulmonalis were also 
among the victims, two others had dothinenteritis, and one had 
organic disease of the heart. Forty-eight cases came from 
the city ; fifteen were taken sick in the wards, and of these 
thirteen died ; twenty had looseness of the bowels previous to 
the characteristic symptoms, and among twelve the diarrhoea 
lasted more than* eight days. In the period of reaction, 
a large blister was sometimes placed over the epigastrium, 
and where there was a foul tongue and loss of appetite, 
ipecacuanha was given. Only two deaths occurred during 
reaction, the symptoms of which were benign. 

This report is somewhat imperfect, since it does not state 
the comparative number of deaths among the mild and the 
severe cases. Dr. Parrot is of opinion that, making proper 
allowances for the moribund, as well as those laboring under 
previous diseases, the recoveries would nearly balance the 
deaths. It is worthy of notice that thirteen of those who 
were attacked in the hospital, died, and that only two deaths 
occurred during reaction. 

The following outlines of treatment are extracted from 



118 ASIATIC CHOLERA. 

lectures on the subject by Dr. Maclean, whbh were con- 
tained in recent numbers of the London Lancet.* 

" Secure the best hygienic conditions possible for your 
patients ; avoid crowding them, give abundance of water to , 
drink, and ice to suck; correct cramps and inordinate 
vomiting by the internal and external use of chloroform ; 
apply external warmth and extra bed-clothes if they are 
grateful to the patient, but if they make him restless, do 
not press them. If the cuticular discharge is excessive, 
wipe the patient dry from time to time, disturbing him as 
little as possible. If vomiting be not excessive, and if the 
remedy does not excite it, ten drops of the mixture I have 
recommended (see Formula No. 3) in the premonitory diar- 
rhoea, may be given from time to time, chloroform being 
substituted if vomiting be urgent. As soon as vomiting 
ceases, you must support the patient by proper nutriment. 
At first I begin usually with thin arrow-root well boiled 
and flavored with a little aromatic. I give this commenc- 
ing with a teaspoonful at a time, giving now and then a 
teaspoonful of brandy in it, never overdistending the 
stomach. Instead of water, I now quench thirst with milk 
containing a little lime-water, and flavored, if it be at hand, 
with a few drops of cura9oa. This may be often given to 
the patient with a little soda-water. As reaction proceeds, 
I substitute strong beef-tea, or better still, essence of meat, 

* Lectures on the Treatment of Cholera, by Deputy Inspector Ge- 
neral Maclean, M.D., Professor of Military Medicine. London Lancet, 
Feb. 3d and 17th, 1866. 



ASIATIC CHOLERA. 119 

using it in the same cautious way, spoonful by spoonful, at 
proper intervals ; later still, eggs beaten up with a little 
brandy, and flavored as before with curacoa, are often rel- 
ished. The greatest caution is required not to disgust the 
patient, not to re-excite vomiting, not to over-stimulate, so 
as to bring on cerebral symptoms, during the febrile reac- 
tion. When patients are thus carefully nursed, it is seldom 
that reaction is excessive. Nothing but mischief may be 
expected from over anxiety to hasten forward convales- 
cence by too freely pressing food and stimulants on the 
patient." Dr. Maclean also says : " When I first went to 
India it was a common practice to withhold water, espe- 
cially cold water, from cholera patients. Following the 
routine of the day, I have acted in this way, and I was 
taught by personal experience the folly of this article of 
prevailing medical belief. There is no necessity to give 
large draughts, but let not the fact that a portion of al- 
most every supply is vomited, lead you to withhold it 
entirely. 

" Cramps are best relieved by the use of chloroform, given 
in doses of five or six minims in a little water ; and if vomiting 
be excessive, a little may be sprinkled on a pad of lint covered 
with oiled silk or gutta-percha tissue, and applied to the 
epigastrium ; or spongio-piline may be used for the purpose. 
I have used chloroform in this way, both externally and 
internally, very freely, and always with good effect." 

In the same lectures from which the preceding extracts 
are taken, an opinion is strongly expressed against the use 



120 ASIATIC CHOLERA. 

of opium. It seems, however, to refer especially to its use 
in large doses, or during collapse. 

" In the stage of collapse, if it is retained, it is, it must 
be, useless. But when reaction sets in, the opium, previ- 
ously inert, begins to act, and is at once a serious hindrance 
to the restoration of the secretions, and if the quantity 
given has been large, often hastening on cerebral symptoms, 
ending in coma." 

In a recent meeting of the New York Academy of 
Medicine, Dr. John T. Metcalfe gave very briefly his views 
with regard to the treatment of cholera. He recommended 
in the first stage rest, warmth, quiet, pure air, and proper 
diet. Frictions of the extremities, inhalations of chloro- 
form, or hypodermic injections, may be used against the 
cramps. Warmth should be applied to the epigastrium, 
and cold water allowed freely. In collapse, no large doses 
of opium should be given: external warmth should be 
applied and cold water administered internally ; the cold 
water to be used, even if it cause vomiting. Consecutive 
fever is to be treated on general principles. 

Dr. Niemeyer is of opinion that every one attacked, even 
with a slight diarrhoea, during a cholera epidemic, should 
send immediately for a physician, and in the meantime go 
to bed, keep warm, and drink several cups of hot coffee* 
or herb tea, the object being to produce perspiration. If 
there is any delay in the arrival of the physician, the 
patient should take small doses of opium, in the form of 

* Hot coffee has with some persons a decided laxative effect. 



ASIATIC CHOLERA. 121 

paregoric or laudanum. He considers opium in the early 
stage of the disease as one of the most effectual remedies, 
and recommends the Russian Cholera Drops (see Formula 
No. 2). He, himself, gives the tincture, or Dover's powder. 
If the patient improves under this treatment, then it is 
continued in small doses, until a firm stool passes from the 
bowel; if the patient grows worse, calomel in one grain 
doses should be substituted, and cold water applied to the 
abdomen. The patient is also allowed to swallow small 
pieces of ice, or small quantities of ice-water. As collapse 
approaches, stimulants are indicated, and by preference iced 
champagne, which stimulates the nervous system without 
affecting injuriously the coats of the stomach and intestine. 
The aethereal oils, carbonate of ammonia, and other sharp 
substances, are less desirable. In practice among the poor, 
rum and water may be given. Sometimes a cup or two of 
hot, strong coffee, may be advantageously taken between 
the draughts of water. Although the coffee will not be long 
retained, there will be an improvement in the pulse and 
temperature of the skin before its ejection. A cessation 
of the discharges caused by paralysis of the muscular walls 
of the bowel, shown by the continued asphyxia, indicates 
an increased necessity for stimulant, and the reappearance 
of the discharges shows that the bowels are recovering their 
tone. Frictions with mustard may be used for cramps, but 
there is danger in the employment of sinapisms lest they 
be left on too long and cause obstinate and painful skin dis- 
eases. After reaction, great care should be used in the pre- 



122 ASIATIC CHOLERA. 

paration of food, and the diet should consist of milk, broth, 
and toast, until the passages become normal. 

Dr. Drasche considers that the following remedies, which 
have been at different times brought forward as cures for 
cholera, have not fulfilled the expectations formed of them : 
Venesection, calomel, ipecacuanha, salines, terchloride of 
carbon, spirits of ammonia, nitric acid, trisnitrate of bis- 
muth, nitrate of silver, hydropathic measures, strychnine, 
phosphorus, aqua calcis, valerianate of ammonia, hydrated 
oxide of iron, sulphuric and manganic acid, pyroligneous 
acid, gunpowder, castor oil, croton oil, chloride of lime, 
chlorinated water, chlorate of potash, chloric aether, chloro- 
form, animal charcoal, hashish, stachys anatolica, protoxide 
of nitrogen, oxygenated water, salt, used in baths and for 
enemata and injections into the veins, injection of the 
bladder with warm water, inhalation of aromatics, trans- 
fusion of blood, electricity, and curative gymnastics. 
He attaches great importance to a rigid diet in the very 
commencement, nothing but soups being allowed. From a 
neglect of this precaution, has arisen the disappointment which 
many physicians have found in remedies for the diarrhoea. 
Only a limited quantity of fluids may be taken, and this if 
possible warm. If the thirst is excessive, ice may be 
allowed. Patients have stated that the use of cold draughts 
was followed by marked intestinal rumbling, and soon after 
a watery dejection, in spite of preventive medicines. His 
remedy for the diarrhoea is opium, which he prefers to give 
in the form of tincture (tinct. opii crocata). Should the 



ASIATIC CHOLERA. 123 

diarrhoea continue several days without amendment, astrin- 
gents should be substituted for the opium. Of these he 
prefers rhatany and tannin in doses of five grains of each. 

As the collapse approaches, stimulants are indicated, to 
excite the nervous system and quicken the circulation. He 
likes the sethereal oils, as of cinnamon, mint, and juniper; 
musk has also a similar action. If the time presses, diffu- 
sible stimulants, as warm wine, champagne, rum, or punch, 
may be employed. Sulphuric and acetic ethers (stimulant 
antispasmodics) have also a decided action upon the cramps 
and vomiting. Used for inhalation they improve the 
pulmonary circulation, and relieve dyspnoea. The effect 
of ether, thus employed, has often been surprising, especially 
with young persons. In a short time after the commence- 
ment of the inhalation, the pulse has improved, the 
temperature of the body risen, the cyanosis lessened, the 
cramps have diminished, and reaction has set in. 

As an additional means of restoring the circulation, 
frictions should be employed, and the body enveloped in 
warm coverings. Sinapisms are also considered as very 
useful. If reaction is imperfect, stimulants should be used, 
mild or strong, as the circumstances require. If excessive, 
ice may be applied to the head, and cold water allowed. 
If there is a tendency to cerebral congestion, leeches and 
cups should not be employed. To restore the urinary 
secretion, mild diuretics, such as selters water, citric acid, 
or citrate of potassa, are indicated. If necessary, warmth 
may be applied to the loins and frictions made with ungt. 



124 



ASIATIC CHOLERA. 



digitalis, the oil of juniper, or turpentine. A free use of 
cold water is also allowable. 

If the diarrhoea continues during reaction, astringents, 
such as tannin, extract of calumba, and extract of rhatany, 
should be administered. The same remedies are indicated 
if diarrhoea is present in consecutive fever. Vomiting and 
singultus are treated by sinapisms to the epigastrium. So 
long as the period of reaction continues, the patient must 
remain in bed and confine himself to a diet of soups alone. 

For the diarrhoea and vomiting which sometimes con- 
tinue during convalescence, nux vomica is a suitable remedy. 
So long as there is any indication that the digestive organs 
are still suffering, the diet must consist principally of nutri- 
tious soup&. 

An analysis of two hundred and thirty-four cases of con- 
secutive fever treated by different remedies shows the fol- 
lowing results. 



56 cases were treated by salines, 


of which 21 died. 


22 " " mercurials, 




6 " 


101 " " aperients , 




8 " 


1 " " diuretics, 




— " 


21 " " stimulants, 




14 " 


3 " " external irritants " 


2 " 


5 " u nourishment alone " 


2 " 


23 treatment not recorded .... 




3 " 


2 not treated by medicine .... 




1 " 



" In the practice of one practitioner at Paisley the remark- 
able number of one hundred and three cases of consecutive 



ASIATIC CHOLERA. 125 

fever occurred in one hundred and ten cases of cholera, 
sixty of which passed into the fever without having had 
collapse. In all these cases calomel and opium were used 
as the prominent treatment in the previous stages. There 
is no evidence whether the opium was given in unusually 
large doses. The result, however, corresponds with the 
large proportion of cases of consecutive fever in the metro- 
politan hospitals, in which the use of opium combined with 
chalk appears to have been attended with a similar result."* 

The outlines of treatment which have been introduced 
are drawn but from a few sources. This is not because 
there is any lack of advocated remedies in the immense 
field of cholera literature ; but many of the remedies have 
been laid aside, many are but repetitions of others, and the 
consideration of too large a number would involve conside- 
rable perplexity. A comparison of those which have been 
chosen will afford an opportunity for a selection from differ- 
ent methods. 

Without venturing any positive opinion upon a subject 
which is still involved in so much obscurity, it would seem 
that, judging the disease by its origin in the midst of highly 
malarious influences, and in the presence of animal filth, f by 
its tendency to produce septic alterations in the blood, J its 
spasmodic character, and its disposition to fall upon the 

* General Board of Health, Report on the Results of Different 
Methods of Treatment. Med. Times & Gazette. Oct. 21, 1855, p. 422. 
f Appendix, p. 134. 
% Appendix, p. 138. 

7 



126 ASIATIC CHOLERA. 

nervous system, a medicine containing quinine, in com- 
bination with an astringent and antiseptic, like sulphuric acid, 
an antispasmodic like chloroform, an anti irritant like opium, 
which also possesses other valuable properties (see page 102), 
and some diffusible stimulant, would fulfil the promi- 
nent indications for treatment in the early stages of the 
disease. With the approach of collapse, opium should be 
discontinued. Abstinence from food is also indicated in 
the commencement of the diarrhoea, and simple unirritating 
nutriment as the disease progresses. 

Ice taken internally tends to relieve thirst and modifies 
the irregular distribution of heat. Cold drinks are more 
eagerly sought for by cholera patients than warm, and are 
recommended by good authority, especially in collapse. 
Judging from analogy, the coverings for the body should 
be light or warm in the algid stage, as the sensations of 
the patient may dictate. 

Applications of dry cold along the spine have been 
apparently found so useful as to be worthy of a trial. The 
assertion that the circulation in the sympathetic ganglia 
cannot be affected by ice applied along the back is denied ; 
perhaps the effects of this remedy are due in some degree 
to the influence which impressions made on cutaneous 
nerves produce upon internal organs. 

As Dr. Worms recommends sulphuric acid so warmly, 
and as emetics have sometimes been found so useful in 
rousing the system from collapse, this medicine, which acts 
as an emetic (antispasmodic) in the algid stage, and is also 



ASIATIC CHOLERA. 127 

tonic and antiseptic, seems to offer some hope of useful- 
ness. 

A mass of minutely detailed observations upon remedial 
measures, as employed in this malady, is much needed, for 
the purpose of acquiring clearer views of treatment. 

Such facts would also be of advantage in aiding to arrive 
at a knowledge of the essential nature of cholera, since, as 
has been well said, one of the principal uses of medicine is 
to throw light upon the nature of disease. 

FOKMULJE. 
No. 1. — In Diarrhcea and Cholera. 

IJ . Chloroform. 3 ij. 
Spts. Camphorae, 
Tinct. Opii, da f 3 iss. 
Olei Cinnamomi gtt. vij. 
Alcohol, f 3 iij. 
M. 
S. Dose from five to thirty minims or more as required. 

No. 2. — Eussian Cholera Drops. 
3 • Tinct. Valerian, seth. 3 ij. 
Vin. Ipecac. 3 i. 
Tinct. Opii camph. gtt. xx. 
01. Menth. piper, gtt. v. 
M. 
S. Twenty drops every hour. 

jSTo. 3. To PROMOTE REACTION IN CHOLERA AND DlARRHCEA. 

?. 01. Anisi, 

01. Cajeputi, da 3 iss. 



128 ASIATIC CHOLERA. 

Elixir acid. Halleri, 
Tr. Cinnamom. da 3 ij. 
M. 
S. Dose, ten, fifteen, twenty drops, with fifteen or twenty 
drops of Tr. Opii, at short interials. 

No. 4. — A modification of No. 3. 
3 . Olei Anisi, 
" Cajeputi, 
" Juniperi da 3 ss. 
Ether, sulph. § ss. 
Liq. acidi Halleri 3 ss. 
Aquas Cinnamomi § ss. 
M. 
S. Ten drops every quarter, half, or every hour. 

No. 5. 
3 . Chloroform. 3 L 

Olei Terebinthinse § i. 
Aquae destillatae 3 iij. 
M. 
S. Dose a teaspoonful. 

NO. 6. DIAKKH03A AND COLLAPSE. 

3. Ammonias muriat, 

Potassae Chlorat. da 3 i. 
Tinct. Opii carnph. § iss. 
Aq. Cinnamomi § ivss. 
M. 
S. A teaspoonful to be given at short intervals until one is 
retained. Then the same quantity every two, three, or four 
hours. 



ASIATIC CHOLERA. 129 

This prescription has been found useful in the out-door prac- 
tice of the New York Northern Dispensary. 

No. 7. 

5. Tr. Opii, 

Spts. Camphorse, 
Spts. Terebinth! nse da 3 iij. 
01. Menth. pip. gtt. xxx. 
M. 
S. A teaspoonfal in brandy and water for diarrhoea, a table- 
spoonful for cholera. 

For an enema add a teaspoonful of laudanum to a table- 
spoonful of prepared starch. 

No. 8. 
Dr. Barraut's treatment, founded on that adopted by M. 
Leolerc in 1854. 

For Adults. 
IJ. Ext. Belladonnas gr. i every half hour until color returns 
to the surface and pupils dilate. Then it should be given every 
second or fourth hour, until the urine appears, when it should 
be stopped entirely. 

For Children. 
]J . Tinct. Belladonnas (London Phar.) 3 i. 
(The Tinctut e of the London Pharmacopoeia is about half the 
strength of that of the U. S. Dispensatory.) 
Aquae I i. 
M. 
S. A dessert-spoonful every ten minutes with the same 
restrictions. This medicine relieves choleraic diarrhoea, but 



1$0 ASIATIC CHOLERA. 

not an ordinary diarrhoea. The pupils dilate, and in correspon- 
dence the skin becomes warm and dry, and this warmth may 
become excessive if pushed too far. With this treatment, in 
Mauritius, there were only ten deaths in fifty-eight cases 
treated in 1859, and during 1862 the mortality' was small, 
only eighteen dying. As a drink the white of egg^ beaten up 
in a glass of cold water, allays this more than an effervescing 
draught. When cramps have been severe Dr. Barraut has seen 
excellent effects from subcutaneous punctures with a lancet 
moistened with a solution of tincture of atropine. 

If it be true that there is a vascular spasm present in cholera, 
and that belladonna is efficacious in arresting the disease in its 
early stages, it may be accounted for by the relaxing influence 
of the drug upon organic muscular fibre through its effect upon 
the nervous system. 

No. 9. 
Eemedies used by the American missionaries in Constanti- 
nople (1865). 

For the Diarrhcea. 

?. Ti\ Opii, 
Tr. Bhei, 

Spt. Camphoras, da. 
S. Thirty drops, for an adult, is the initial" dose, generally 
doubled if a second dose is necessary ; severe cases, sixty drops 
for the first dose. 

For tiie Vom.ting. 
9 . Tr. Opii, 
" Capsici. 



ASIATIC CHOLERA. 131 

Cardamom, comp. 
" Zingiberis da. 
M. 

S. Thirty, forty, or more drops p. r n. 

From August 1st to August 28th, of one hundred and two 
cases of cholera found in bed, eighteen died, "the others 
have recovered or are recovering." — Chicago Medical Examiner, 
May, 1865. Correspondence. 

Philippine Islands Remedy. — At the first appearance of the 
symptoms rub the whole body, especially the bowels, with a 
brush dipped in brandy. Give a cup of warm mint or imperia 
tea, containing sixty drops of ether, and wrap the patient in a 
warm covering. If perspiration does not appear in four minutes, 
give another cup of tea containing eighty drops of ether, when 
it is said that perspiration is sure to follow. Occasionally a 
third cup is required, with 120 drops of ether. (It is a question 
whether this treatment would not be equally effectual without 
the frictions, external warmth being substituted.) 



APPENDIX. 



Nature and Origin. 



The Resemblance of the Disease to Tetanus. — Mr. Crew, Super- 
intending Surgeon in Malwa, stated (July 30th, 1818) : 

" Notwithstanding the early exhibition of the remedies, the 
disease yet appears to run through a kind of course ; for the 
symptoms of coldness and total absence of pulse frequently 
take place where there appears to have been but little disturb- 
ance in the primse viae." — P. 45. 

il The disease, as affecting many of the Europeans, appears 
to me to be a true Tetanus." — P. 63. 

(Notes on the Epidemic Cholera, by R. Hartley Kennedy, 
M.D., &c, &c, late Physician General and President of the 
Medical Board of Bombay. London, 1846.) 

Dr. Kennedy was stationed in Surat in 1818, and it was in 
the end of August that the epidemic showed itself at that place. 

Mr. Barnes, Surgeon in the Hon. East India Company's Ser- 
vice, resident at Jessore for many years, thus writes : 

" I had medical charge of the district of Jessore, in Bengal, 
from 1810 till the end of the year 1822, with an exception of 

7* 



134 APPENDIX. 

part of 1816 and 1817. I was, therefore, absent at the time 
the disease now called Indian Cholera Morbus first assumed 
the epidemic character. I had, however, been .intimately ac- 
quainted with the disease ^s endemic, from the time I first 
joined the station, but never dreamt of giving it the name of 
Cholera Morbus. I considered it altogether a new disease, un- 
known to all the medical writers whose works I had read, 
peculiar to that part of the country, and to have superseded the 
periodical remittent fever formerly so prevalent in that district. 

" The causes of this disease could not be mistaken, although 
they were of too extensive a nature to be brought under human 
control. Putrid exhalations from the constant and rapid de- 
composition of animal and vegetable matter, and the use of 
unwholesome water, were the sole causes of this disease ; and 
the extent and fatality of its progress during the time it was 
endemical depended altogether upon the season. If those vio- 
lent storms of thunder, lightning, wind, and rain, which annually 
occur in Bengal, and are known by the name of northwesterns, 
commenced early in March, and recurred at short intervals 
until the rainy season began, the hot season (as it is called), 
namely April, May, and June, was comparatively healthy, and 
vice versa. 

u Again, if the rain did not terminate till the end of Septem- 
ber, and the floods subsided gradually during the month of 
October, the autumn season was free from extensive sickness ; 
but if the rains broke up at the end of August, and the waters 
sank rapidly during September, the disease commenced its 
attack among the natives at the beginning of October, carrying 
death and desolation in its progress, until about the middle of 
December, when the complaint became checked, and in a short 
time apparently extinct. Twice previously to 1817, this dis- 



APPENDIX. 135 

ease prevailed to such an extent in the town of Jessore and its 
immediate neighborhood, as to render it necessary to shut the 
courts of justice and to suspend all business for a time. 

" The great changes in the seasons of 1816 and 1817 rendered 
the atmosphere peculiarly favorable to the extension of the 
disease beyond its usual limits, favored its progress by con- 
tagion, and assisted in generating the pestilence throughout 
those parts of Bengal where the materials necessary for its 
production existed, but probably in a less extensive degree than 
in Jessore. 

" Instead of the usual rainy and dry seasons, there was scarcely 
a week during 1816 without rain in the district of Jessore, 
from the beginning of January to the end of December. The 
sun was constantly obscured, the atmosphere close and heavy 
and moist, with the thermometer varying from 70 to 75 
degrees from March to iSTovember. 

" In such a climate as this, any person acquainted with the 
materials that compose an Indian camp, and with the crowded, 
filthy, and ill-ventilated state of the houses and streets of 
Indian cities and towns, must be satisfied that those, of all 
others, are the places most favorable to contagion. 

" The huts of the natives are nearly surrounded with pits, 
the earth from which has been used to raise mounds on which 
their habitations are erected. These pits are the receptacles 
for every kind of filth, as well as stagnant water, and the 
exhalations from them at times are almost insufferable." 

The Phenomena of Pestilential Cholera, etc., by George 
McCulloch, MD., F.K.C.S. (Dublin), and H. C. Maelaran, 
M R.C.S. London, 1850. See page 27 et seq. 

" The physician who has been able to follow the march and 



136 APPENDIX? 

observe the features of the cholera epidemics which have 
appeared since 1832, must come to the conclusion that the dis- 
ease, since its first appearance, has been undergoing an inces- 
sant and successive transformation. 

" During the epidemic of this year (1865), which has assumed 
such large proportions, having been commissioned to observe 
the disease in Alexandria before it showed itself in Cairo, I was 
obliged to declare in my report that the disease which ravaged 
Alexandria was not the true Indian cholera. The view which 
I took of it is shown by my prescriptions, which consisted 
mainly in the use of quinine. I also judged, from cases ob- 
served in Beyroot, that the epidemic which afflicted Syria was 
similar to that which prevailed in Egypt. Dr. Koutoula, prac- 
tising in Syria, a man of great experience in cholera, assured 
me that the disease did not present the features of true Indian 
cholera, but could more justly be regarded as a pernicious 
cholera. Dr. Maurin, writing from Marseilles that the cholera 
has characteristics similar to those of typhoid fever, observes 
that " one is struck with the presence of a pernicious element, 
which is suggested by the course which the disease runs, and 
the mingling together of sweating, intermissions, and choleraic 
symptoms." 

"Cholera: Difference de ces Caracteres suivant les lieux et 
les temps. Dr. E. Eossi Bey, of Cairo." Gazette des Hopitaux, 
Dec. 9th, 1865. 

" In summing up the evidence regarding the cause and nature 
of cholera, it may be stated then that there is a poison, the 
exact nature of which is not perfectly understood ; that this 
poison introduced into the system causes disturbance of innerva- 
tion, or a sort of paralysis of the ganglionic nervous system ,• 



APPENDIX. 137 

that this leads to extensive hyperemia of the alimentary canal, 
resulting in the symptoms described, and to the reflex pheno- 
mena alluded to, and as the disease progresses, obtaining more 
or less an inflammatory character. 

See Dr. Alonzo Clark's Lectures on Cholera, Nos. 2 and 3 of 
the Medical Record, N. Y. 

The point of departure of M. Marey's theory is the resem- 
blance which he finds between cholera and paroxysmal fevers, 
which latter he considers as under the control of the vaso-motor 
system of nerves. 

In the peripheral vascular system, there is a muscular enve- 
lope, which surrounds the minute vessels, and is supplied by 
branches of the grand sympathetic. A contraction of this mus- 
cular apparatus produces a diminished calibre of the vessels and 
a decrease of circulating blood. The opposite is true of a re- 
laxation of this muscular tissue. 

Hence the algid symptoms are a result of the contraction of 
these vessels, in consequence of increased action of the vaso- 
motor nerves, and since every violent and long-sustained effort 
causes fatigue and weakness, so, after this intense contraction 
of the vessels, follows a relaxation or a febrile condition ; that 
is, the extreme vessels allow a greater amount of blood to pass, 
and the surface becomes warmer. The collapse depends upon 
increased action (irritability) of the sympathetic, and reaction, 
upon its exhaustion. 

(Essai de Theorie Physiologique du Cholera, par le docteur 
Marey. Gazette Hebdomadaire, Nov. 24th and Dec. 1st, 1865.) 

The paralysis induced by anaesthetics, such as ether and 
chloroform, furnishes an instance of the manner in which a 



138 APPENDIX. 

morbid process may be developed in the system by an agent 
which is introduced through the lungs. 

M. Baudrimont, who has been making observations upon the 
blood of cholera patients was led by his researches to the 
following conclusions. 

In cholera the blood is profoundly altered. It has lost largely 
of serum which is represented by water, albumen, and salts. The 
other elements (globules and fibrine) have also lost the property 
of coagulation. The albumen has become converted into dia- 
stase, possessing the property of dissolving starch granules. 

This diastase is also present in the dejections. 

The mucoid matter contained in the evacuations from the 
stomach, exists as described by Andral (who found it to be 
formed of cells analogous to those in pus), but these evacuations 
also contain spherical globules ot a hundredth of a millimetre 
diameter, similar to those which constitute brewer's yeast. 

This presence of diastase and of a substance analogous to 
brewer's yeast is remarkable; since these substances represent 
two products which are formed successively at the expense of 
the albuminoid matter of the barley during the germination of 
this grain and the fermentation of beer. 

(Recherches experimentales et Observations sur le Cholera 
epidemique par M. Baudrimont. Gazette Hebdomadaire, Nov. 
17 th, 1865.) 

See also the Richmond Medical Journal for March, 18 ^<6, p. 265. 
Epidemic Influence. * 

Paris, Oct. 16th, 1865. — a ]STow, as in 1853, ordinary diseases 
follow their usual course without seeming sensibly affected by 
the presence of the epidemic, and without bearing that impres- 
sion generally observed in great epidemic-, especially in those 
of 1832 and 1849." Gaz. des Hopitaux, Oct, 17th, 1865. 



APPENDIX. 139 

" The cholera of Marseilles, in 1865; has the characteristics of 
typhoid fever; the predisposing causes are fatigue and wretch- 
edness; debility is its marked feature; it does not rage among 
those suffering from other diseases; there is not that epidemic 
influence present which seems to settle upon a city and modify 
all diseases." 

Caracteres du Cholera de Marseille en 1865. Par le docteur 
Selim Ernest Maurin. 

In Naples the number of cases began to increase coincidently 
with the sirocco wind. So the sirocco was the cause of the 
cholera. The shvcco theory lasted till the wind changed and 
blew from a northerly direction, " with greater violence than 
had been known for years before." Still the malady got worse, 
" and the greatest havoc committed by it was almost all on 
those blustering days." London Lancet, Dec. 9th, 1865. 

DlARRHCEA. 

" In regard to the duration of diarrhoea, the following facts are 
presented, which were collected at the beginning of an epidemic. 
The diarrhoea lasted before the occurrence of other symptoms: 
In one case two and a half hours, ten evacuations ; in another 
two days ; in another, there was no diarrhoea until the cramps 
occurred, and then only four evacuations before collapse; in 
another, none until cramps set in, when it became very severe ; 
in other cases, it lasted respectively ten, two, two, thirty, 
thirty-six hours, two and a half days, and three weeks. Dr. 
Buel, physician to one of the cholera-hospitals in New York 
during the prevalence of an epidemic, calculated the average 
duration of the diarrhoea in 469 cases as three da} r s and six 
hours. 

Lectures on Cholera by Dr. Alonzo Clark. 



140 APPENDIX. 

" The premonitory period is marked by extreme lassitude ; 
the least exertion of muscular force is followed by sensation of 
great fatigue in the knees and elbows. The functions of the 
skin are badly accomplished, the perspiration being abundant, 
even although the body is cool. The tongue is not exactly 
furred, since it is white in the centre, and red at the tip and 
edges. Patients complain of a bad taste in the month, food has 
less relish, and although the wish for solids decreases, there is 
an increased desire for liquids; yet nevertheless the stomach is 
discommoded by a very small amount of fluid. 

" There may be constipation, and then the stools of those who 
have used alcoholic liquors in excess are dark; the head feels 
heavy, there is a sensation of weight in the frontal sinus, and 
the marked characteristic is an absolute prostration of strength. 
If a critical vomiting occurs, it is marked by immediate and 
decided relief. If diarrhoea takes the place of constipation, the 
relief is less decided, yet appreciable, and it is this circumstance 
which deceives a large number of patients ; for observing that 
this black and fetid diarrhoea refreshes, instead of weakens 
them, they do not apply to a physician. 

" Such is the ordinary commencement of our Cholera." 

Character of the Cholera in Marseilles in 1865. By Dr. Selim 
Ernest Maurin. Gaz. des Hopitaux. Samedi, 30th Sept., 1865. 

C OMMUNIC ABILITY. 

In reply to that theory which holds " that cholera epidemics 
and individual cases are almost always preceded for some 
weeks, if not months, by diarrhoeas," M. Pellarin, in the Gazette 
des Hopitaux, Pet. 10th, 1865, offers bis experience of cholera 
in 1849. 

At the outbreak of cholera in the garrison of G-ivet, the force 



APPENDIX. 141 

consisted of 1,599 men, counting at the hospital in all 33 pa- 
tients, of whom 17 had fever, 8 were wounded, 7 had venereal 
disease, and 1 the itch : that is, there was one man in the 
hospital for every 48.46, and a fever patient among every 96 ; 
figures which show that the sanitary condition was little 
affected by supposed premonitory epidemic influences. The 
cholera was introduced at G-ivet by a servant who arrived from 
Brussels on the 17th August, and who showed characteristic 
symptoms on the same day. The first ease in the garrison was 
that of a grenadier who visited the servant during her sickness, 
especially on the day of her death. He was attacked at eleven 
o'clock on the evening of that day with well marked symptoms, 
and died at seven in the morning; eighteen other soldiers com- 
ing from the same barracks, which were occupied by only two 
companies, were also attacked. 

Fumay is twenty-two kilometres from G-ivet, in ascending 
the Meuse. From the 17th August, when cholera showed 
itself at G-ivet, until the 11th October following, the inhabitants 
of Fumay, mostly workmen in slate quarries, had not suffered 
from any unusual change in their general health. 

On the 11th October, a battalion of the 63d de Ligne left 
Givet for Fumay, which is the first day's march. On the route, 
a fusileer (Pierre G-uerin) was seized with choleraic symptoms. 
He was carried by water to Fumay, and died on the following 
day. Two days later a case occurred in the population of this 
small city, and up to the 26th November the epidemic had 
claimed 130 victims among three thousand inhabitants. 

(Notice of a paper addressed to the Academie des Sciences, 
by Dr. Ch. Pellarin, Gazette des Hopitaux, October 10th, 1865). 

"The following instance of contagion, vouched for by ad- 



142 APPENDIX. 

ministrative documents across a vast extent of country, from 
Elvas to Oporto, has fully awakened society to the dangers of 
material contact : — A young married woman of Oporto, on a 
visit to her sister at Elvas, left the latter city on October 14th, 
on occasion of her nephew being attacked with cholera. She 
reached Oporto on the 17th, and on her arrival bore an appear- 
ance of malaise. The woman who was her nurse, a young 
and robust female, immediately returned to her lodging in 
another ward of the city, and this person was violently attacked 
on the day following, viz. October 25th. She still survived, 
but in a dangerous condition, on November 4th last. This 
nurse's landlord, a small tradesman, was seized with cholera, 
and died during the course of the nurse's illness. In the mean- 
time, two brazier's apprentices, in the house of the first named 
female, were attacked with cholera, and died in the hospital 
whither they had been removed." 

(Cholera in Spain and Portugal, Medical Times and Gazette, 
December 16th, 1865.) 

There had never been a case of cholera in the village of Puix 
previously to August 13th, 1854. On that day a travelling 
beggar arrived from Belfort, where there was an epidemic of 
that disease. He was taken care of by Marsot, marechal of 
the village, fell sick, and died with all the symptoms of algid 
cholera. On the 16th, Marsot was attacked and recovered. 
On the 18th, the woman Stenacre, who had prayed near the 
corpse of the first victim, was seized with the disease, and died 
on the 22d; her husband, who, in spite of the warnings of the 
physician, had continued to occupy the same bed, also died of 
cholera. Her three children were washed, dressed in clean 
clothing, and taken away, and the house was closed. On the 



APPENDIX. 143 

25th, Perrot, a neighbor of Stenacre, was attacked and died 
of the disease. Another neighbor sent away his workmen; 
two of them took lodgings with Collin, who lived at the other 
extremity of the village. One of these, Courtenant, fell sick 
on the 29th, and started for his native village, two leagues dis- 
tant; being unable to continue his journey, he was accom- 
modated in a barn which was the property of Serre. He 
remained there some hours, and was taken away by his wife, 
enveloped in a covering belonging to Serre. On the 30th, 
Muller, another workman lodging with Collin, had cholera and 
died on the 31st. On September 1st, the infant of Collin was 
taken sick with the same disease, and died ; and on the 2d 
September, Desneuty, another pensioner of Collin, was also 
attacked. A servant of Collin, who had remained with the 
last two patients, also died on the same day as Desneuty. The 
wife and children of Collin were sent away by command of the 
physician, who ordered the disinfection and closing of the 
house. The husband alone resisted, and slept in the bed where 
his child had died ; he was taken sick and died on the night of 
the 4th or 5th September. 

His wife, who returned after her husband was taken sick, 
was attacked on the 6th, and recovered. 

On the 29th August, a girl, a neighbor of Perrot, who was 
named Jeannenot, fell sick and recovered. 

To return to the focus of infection created by Collin's house. 
A woman named Copate} T , living in an adjacent house, was 
attacked on the 11th, and died on the 12th; her daughter, who 
had neglected any disinfection, fell sick on the 15th, and died. 
The last case in the village was furnished by Claudel, an ine- 
briate. 

It will be remembered that Serre had lent a covering to one 



144 APPENDIX. 

of the sick men. His wife went for it to the village near, on 
the 29th August, and brought it back upon her head. She was 
seized with cholera on the 2d September and died, being the 
first case in the village of Chaux. Serre refused to destroy the 
articles which his wife had used ; his mother and a young in- 
fant, who occupied the room where she died, fell victims to the 
disease on the 7th and 8th September. 

So from the 13th August to the 23d September, sixteen 
cases of cholera occurred in Puix, the first evidently imported, 
the others immediately connected with it, and the dates of 
their appearance are : 13th, 16th, 18th, 22d, 25th, 29th (two 
cases), 31st, September 1st, 2d, 4th, 5th, 7th, 11th, 15$*, 23d. 
This was the total of cases observed during forty-one days; the 
length of the medium period of incubation for each case being 
sixteen hours. — Gazette Hebdomadaire, Nov. 10th, 1865. 

The first case of cholera in Munich in 1854 was observed on 
the 19th July. This patient had had diarrhoea for eight days. 
The physician in charge of those sent with goods to the grand 
exhibition, five hundred in number, had noticed since the 17th 
July that a large number of them were suffering from diarrhoea. 
On the 25th many were unfit for labor, and every day there 
was an increase of sickness. From the 25th July to the end 
of August, there were but a few who escaped an attack of the 
disease, and eleven died of cholera, 

Pettenkofer observed the influence which 253 of these men, 
who lived in Munich, had upon the spread of the disease. 
These 253 who were treated for cholerine by the physician 
above referred to, lived in 242 houses scattered in 110 streets 
of the city. These 110 streets contained 2460 h >uses. In 843 
of these houses (28.4 in 109) there were cases of cholera. In 



APPENDIX. 145 

242 houses occupied by those sent to the exhibition in charge 
of goods there were 112 cases (46.2 in 170). These houses 
were of a moderate character. In examining the table which 
indicated the cases of cholera according to days, houses, and 
streets, it was observed that those occupied by the class referred 
to, were attacked almost always three or four days before the 
rest. 

Before the 9th March, 1854, no case of cholera had ever been 
observed in La Charite ho-pital. On the 9th and 14th two 
cholera patients, a man and a woman, were placed, one on the 
second and the other on the first story, the most airy in the 
hospital. From the 15th to the 19th, eight cases of cholera and 
six deaths occurred, and all the eight were among patients 
placed near the cholera patients, who had been brought in from 
the city. On the 19th, five new cases appeared, four, in the 
wards already infected and one in a ward more remote, while 
as yet there were only two cholera patients from the city. 

(Dr. Jules Worms : De l'lnvasion de Cholera et de son Mode 
de Propagation.) 

M. Paillard found that of those patients admitted to the 
Hotel Dieu from the 26th March to the 3">st May, 1832, one 
house furnished thirteen, another ten ; five houses gave each 
nine patients, and three eight. 

At Munich in 1836, 326 cases of cholera were treated at the 
hospitals ; 106 of these appeared in connexion with the arrival 
of cholera patients from the city. 

At Vienna, in 1854, the entrance of every new cholera patient 
into the common wards was followed by the appearance of new 
cases. 

The terrible debut of the epidemic of Paris in 1832 was on 
the 26th March ; but the Academy of Medicine knew that a 



146 APPENDIX. 

case had been observed in the Rue des Prouvaires a month 
before. The first ravages of the disease were limited to a single 
street, that of Mortellerie. 

In the Sorbonne quarter, the first case was not observed 
until the 28th March at No. 5 Rue de la Parcheminiree. The 
second case on the 29th was furnished by the same hou-e. On 
the following days cases were observed in the immediate neigh- 
borhood ; it was noj: until the 4th and 5th of April, that the 
disease extended to higher streets. 

" The Yomero, one of the most considerable heights at the 
back of Naples, is the residence of a great number of laun- 
dresses, where a large portion of the dirty linen of the Neapolitans 
is washed. Nineteen of these poor women have been attacked, 
and five have died. The height and healthy air of the Yomero 
seemed to preclude the possibility of cholera ascending there, 
but it has been discovered that the linen of those who had 
died or had been attacked by the malady had been sent up there." 
— London Lancet, Dec. 8th, 1865. 

An individual who had recovered from cholera sent his cloth- 
ing to be washed in his native town of Rovigno, where no other 
cases of cholera occurred except those of three women in his 
family, who washed the clothing, and all of whom died. 

(From a recent work on the cholera in Marseilles, by MM. 
Sirus, Pirondi, and Fabre.) * 



APPENDIX. 147 

Tr ADMISSIBILITY BY CHOLERAIC DlARKHCEA AND DEJECTIONS. 

The idea of attributing the spread of cholera in a great de- 
gree to the dejections is a very old one. Jameson noticed in 
1817 in the English camps the frequency of cases of cholera 
near latrines. 

Delbruck relates, in his narrative of the epidemic in the prison 
of Halle, the pernicious influence of the proximity of these 
places, where the dejections of the sick were cast, upon prison- 
ers who were lodged in cells remote from those places, but 
who made use of them ; the cleansing and disinfection of these 
localities and the burying of the choleraic dejections had the 
effect of restraining the epidemic. 

Daring the cholera in Oxford in 1854, Ackland made similar 
observations, and was led to regard the dejections as one of the 
m@aps of propagation. 

Thiersch's experiments on animals, to which reference is 
sometimes made, were as follows : — 

He mixed small pieces of filtering paper, which had been 
dipped in the rice-water discharges and then dried, with the 
food of a certain number of mice. This imbibition was first 
practised with the fresh discharges, then with some which had 
been vo'ded six days and kept at a temperature of about 55° F., 
and afterwards upon a still older dejection. 104 mice swal- 
lowed fragments of these papers; those who partook of the 
fresh dejections had no bad symptoms, but of the 34 which 
swallowed the paper dipped in discharges from three to nine 
days old, 30 became sick and 12 died. The symptoms pre- 
sented A*ere watery dejections, the disappearance of urinary 
odor, then suppression of urine. There was no vomiting. 
Some showed tetanic spasms before death. 



148 APPENDIX. 

The autopsy revealed congestion of the intestines, separation 
of their epithelium, fatty degeneration of the kidneys, and an 
empty bladder. Papers dipped in dejections of an older date 
did not produce any effect. 

M. Eobin injected the vomited and excreted matter of 
cholera patients into the trachea and veins of two dogs, and 
to a third dog he administered the matter vomited by a fourth 
dog, to which he had given the blood and serum of a cholera 
patient. In the three cases he observed the vomiting and other 
symptoms of cholera. — {London Lancet, January 13th, 1866.) 

On the 24th September, 1854, a young vagrant, who had 
suffered from diarrhoea for five days, was placed in the infirmary 
of the prison of Diebourg. He had been walking a long dis- 
tance, and had already been treated in a penitentiary upon his 
route. No case of cholera had ever been seen in the prison of 
Diebourg previously to his arrival. He was seized with vomit- 
ing in addition to his diarrhoea on reaching the prison, but no 
other choleraic symptoms appeared. On the 12th September 
he left the infirmary completely restored. 

He had occupied a small apartment in common with six 
prisoners affected with phthisis and traumatic diseases. 

On the 29th September, five days after his arrival, one of the 
prisoners placed in this apartment was attacked with cholera, 
on the 30th a second, and on the 3d of October a third. The 
first two died speedily. Cases multiplied in the prison, and of 
249 prisoners, male and female, there were from the 30th Sep- 
tember to the 8th October, 36 cholerines and 38 cases of cholera, 
of which 26 were mortal Only one inhabitant of the city, the 
husband of one of the women employed in washing the clothing 
of cholera patients, was seized with cholera and died. — Gazette 
Hebdomadaire, Nov. 10th, 1865. 



APPENDIX. 



149 



During the epidemic of 1849, a soldier from Paris suffering 
from choleraic diarrhoea arrived at his home in a little village 
twenty-five kilometres from Amiens, where no case of cholera 
had been observed. He was put to bed and cared for. Four 
individuals in the family were attacked with cholera a few days 
after the arrival of this man, who had only a cholerine. Of 
these six persons, four died. — Dr. Jules Worms, Gazette Hebdo- 
madaire, Nov. 10th, 1865. 

On the 20th August, 1854, a man named Grassl was con- 
veyed to the prison of Ebrach. He had been confined four 
days in a prison in Munich, in which were several cases of 
cholera. He left Munich with the diarrhoea, and a short time 
after his arrival in Ebrach, the diarrhoea continuing, he was 
placed in the infirmary. The keeper of the infirmary who took 
care of him was seized with a violent attack of cholera on the 
27th, which proved fatal. The epidemic then spread in the 
prison for males, and also attacked that of the females, com- 
pletely separated. The first victim was the woman Maier, who 
had washed the soiled clothing of Grassl, who, attacked with 
cholerine, had introduced cholera. — Pettenkofer. 

On the 12th October, 1854, cholera suddenly made its ap- 
pearance in the Horfield Barracks, about two miles from Bris- 
tol ; and on the following day I was summoned to the barracks, 
to advise as to what steps should be taken in the emergency. 
The disease had been for some time more or less prevalent in 
the neighboring city ; and the village of Westbury, rather less 
than a mile away, had also quite recently been the scene of a 
severe outbreak of it. In the barracks, being of recent date, it 
had not as yet made much head. On my arrival, I found that 
two men, Cox and Williamson by name, were in hospital, in 

8 



150 APPENDIX. 

the stage of collapse ; and that two others were suffering from 
severe choleraic diarrhoea. 

At the date of this outbreak there were living in the bar- 
racks from five to six hundred men, for whose use there were 
five privies, the whole of which were, as I was informed, in a 
very offensive state. In consequence of the protracted drought, 
the barrack pumps had lately failed, and all the water used in 
the barracks had to be got from a distance. 

With a view to check the spread of the disorder, I advised 
the immediate adoption of the following precautions : — 

1. All discharges from sick men to be received, on their issue 
from the body, if possible, into vessels containing a strong solu- 
tion of chloride of zinc. 

2. All linen tainted with these discharges to be placed, with- 
out loss of time, in water strongly charged with the same disin- 
fectant. Tainted mattresses, and other articles not admitting 
of this treatment, to be burnt. 

3. The privy into which the discharges from the sick had 
been thrown, to be reserved exclusively for that purpose. 

4. That, and all other privies in the barracks, to be thoroughly 
disinfected twice a day by the liberal use of chloride of lime and 
of chloride of zinc, in solution. 

5. All men in barracks to be mustered twice a day, and 
examined as to the state of their bowels. 

6. A watch to be kept on the privies ; and every man seen 
going twice to the privy within a short space of time to be 
treated as a cholera patient. 

7. The men to be prevented from visiting the neighboring 
infected city and village until the subsidence of the cholera 
epidemic. 

The result was that, within the next few days, some eight or 



APPENDIX. 151 

ten cases of severe diarrhoea were detected, which were at once 
dealt with, and which soon yielded to appropriate treatment. 
No other case of confirmed cholera occurred in the barracks. 

(Memoranda on Asiatic Cholera, &c. By William Budd, 
M.D. Bristol, 1865.) 

Quarantine. 

At Salonica, Syra, the Piraeus, and Sicily, where most rigid 
quarantine regulations were established during the last year, 
there was no epidemic of cholera. 

Salonica is the second maritime city of Turkey in Europe. 
No case of cholera was observed in the city, although at the 
lazaretto, among the travellers from Constantinople, there were 
sometimes as many as thirty deaths daily. The invasion of 
nearly all the surrounding villages produced great terror. The 
people rose and threatened to repulse strangers by force, in case 
they were received in the lazaretto near the city. Two ships 
were obliged to withdraw and land their passengers upon an 
island in the Gulf of Yolo. 

On the 9th of July, the Cydnus, coming from Smyrna, wished 
to anchor in the port of Lyra, but cannon were directed upon 
her, and she was forced to put to sea. On the ^Grecian con- 
tinent the quarantine was of the severest character. Importa- 
tion and exportation were prohibited. While keeping out 
everything of a suspicious character, they allowed no ships to 
leave port, lest, by going to contaminated countries, they might 
be exposed to infection. 

As a consequence of the prohibitory measures taken in the 
Papal States, this portion of Italy has also been preserved. In 
G-enoa and Leghorn quarantine regulations also seem to have 
been effectual. — Gazette Heldomadaire, Oct. 20, 1865, p. 658, 



152 APPENDIX. 

and the same journal, Nov. 3, 1865, p. 689. Le Cholera et les 
Quarantaines en 1865, Dr. A. Espagne. 

The following statements were made at a meeting of the So- 
ciete Medicale des Hopitaux, held November 8th, 1865, with 
regard to the effects of isolation during the late epidemic in 
Paris. 

The cholera did not make its appearance at the hospital of 
Saint Antoine until late enough for making special preparations 
against its spread. This was impossible at Lariboisiere and 
Beaujon, hospitals where the first patients had been sent As 
a consequence of special measures employed in Saint Antoine 
for three weeks, no cases originated in the hospital. — M. 
Boucher. 

M. Hillairet states that at the Hospital St. Louis, where per- 
fect isolation had been practised, by placing cholera patients in 
a pavilion at the bottom of the garden, there had only been 
twelve or thirteen cases which commenced in the hospital. 

M. Bucquoy stated that in the military hospital of Gros- 
Caillou, where 180 cholera patients from outside had been 
isolated in a pavilion situated in a garden, no cases had origi- 
nated in the hospital. The choleraic dejections had been imme- 
diately disinfected by sulphate of iron. 

M. Bernutz observed that the same precautions had been 
taken in the cholera service of the Hopital de la Pitie. Here 
30 cases had originated within the hospital, and 131 had been 
brought from outside. Among the cases which, appeared pri- 
marily within the hospital, twelve came from a surgical ward 
near to the apartment containing the bedding which had been 
used by cholera patients. — Gazette Hebdomadaire, Nov. 10th, 

1865. 

"On the 22d of last July the first case of cholera appeared 



APPENDIX. 153 

at Barcelona. It was a priest recently arrived from Valentia, 
where the disease had been prevailing fifteen or twenty days. 
From the 25 th July to the 10th August there was no death 
from cholera. But on the night of the 10th and 11th August, 
there were seven cases, and from that time they followed un- 
interruptedly. I have no doubt, as a result of my researches, 
that the first persons attacked were in more or less immediate 
connexion (rapport) with the patient of July 22d. I followed 
the first eight cases step by step."— (Letter from Dr. Ribell of 
Barcelona to the Editor of the Gazette Hebdomadaire, Nov. 
17th, 1865.) 

In 1832 a stage driver affected with cholera came to the town 
of Somers, in Westchester Co., New York State. There was 
then no cholera in Somers, nor was there railroad communica- 
tion between the town and New York. From the time when 
the stage driver arrived the disease spread throughout Somers, 
and one in four of the inhabitants was attacked. Half of those 
who had the disease died. 

Treatment. 

The following carefully arranged table of twenty-five cases 
is interesting as showing the results of treatment by evacuants. 
The diarrhoea was treated with sulphate of soda in purgative 
doses. Ipecacuanha was used when there was a furred condi- 
tion of the tongue. These were the principal medicines 
given. 

From Oct. 20th to Nov. 1st there were thirteen deaths among 
fifteen cases ; from Nov. 1st to Nov. 9th two deaths among ten 
cases. The latter were among children, and during the decline 
of the epidemic. 



154 



APPENDIX. 



Bates. 


Profession and Age. 


Constitution. 


Recovery. 


Deaths. 


Oct. 20. 


Mason, 48 years 


Debilitated . . . 




Oct. 21. 


" 20. 


Mason, 26 years 


Good 




14 26. 


" 21. 


Mason, 53 years 


Good 




" 22. 


" 22. 


Mayor of city, 66 years . . 
Miller, 36 years 


Good 




44 24. 


" 23. 


Good 


Nov. 5th. 




" 24. 


G-ardener, 36 years 

Fruiterer, 49 years . , 

Laborer, 29 years ... 

Fruiterer, 52 years 

No profession, 33 years.. 
Scieur de long, 47 years. . 

Infant, 15 months 

Infant, 2 years 


Feeble 


" 29. 


" 24. 


Good 




44 29. 


" 25. 


Good 




" 28. 


" 25. 


Good 




44 28. 


" 28. 


Good 


Nov. 2d. 




u 28. 


Good 


" 31. 


" 30. 


Good 




14 80. 


M 30. 


Good 




Nov. 1. 


" 31. 
" 31. 


Gardener, 41 years 

Infant, 3 weeks 


Good 

Good 


Nov. 11th. 


Nov. 1. ' ' 


Nov. 1. 


Infant, 9 months . . 

Infant, 18 months 

Joiner, 47 years 

Scieur de long, 18 years. . 

Journalist, 30 years 

Child, 8 years 

Child, 6 years 


Feeble 




44 2. 


" 3. 


Feeble 






" 3. 


Good 

Good 

Fair 


Nov. 11th. 
Nov. 11th. 




" 3. 




" 3. 




" 4. 


Weak 






" 4. 


Weak 






" 4. 


Child, 2 years 

Child, 12 years 


Weak ...... . 




Nov. 8. 


" 7. 


Good 






" 9. 


65 years 


Worn out 




Nov. 10. 











—Gaz. des Hopitaux, Nov. 25, 1865. 

It has been supposed that copper is a preservative against 
cholera, and that artisans engaged in working in this metal are 
not likely to be attacked by the disease. Dr. Mesnet (Archives 
Gren. de Medecine, Feb. 1866) reports eight cases which occurred 
in the hospital of St. Antoine, during the late epidemic, among 
workers in copper ; of eight attacked, five died in collapse. 

Rum and tea were used as drinks for cholera patients during 
the prevalence of the epidemic in Paris. The elixir of the 
Grande Chartreuse was found to act remarkably well in some 
cases as a stimulant. The high price of this cordial would 
prevent its general employment. 



APPENDIX. 



155 



Table of the Total Number of Cases (3,727) of Cholera treated 
in the Metropolitan Hospitals and Districts, and in the Provin- 
cial Districts throughout England and Scotland, showing the 
percentage of Mortality. 






Of 2,142 cases treated by alteratives. 



637 calomel, small doses. . 

767 " larger doses 

472 " with opium 

80 other preparations of mercury. 
186 salines 



Of 865 cases treated by astringents. 



488 sulphuric acid 

27 other mineral acids 

201 chalk mixture and chalk and opium. 

81 acetate of lead and opium 

36 opium 

13 preparations of iron and alum 

19 gallic acid and other astringents 



Of 548 cases treated by stimulants. 



114 ammonia 

154 ether 

138 brandy 

31 chloroform 

Ill other internal and external stimulants. 



Of 172 cases treated by ebiminoMts. 



150 castor oil . 

21 emetics... 

1 olive oil . . 



416 
590 
295 
59 
140 



90 
73 
103 
23 
80 



134 

21 






94 315 

160 353 

140 169 

17 42 

40 94 



65 235 

3 11 

38 55 

26 50 

14 11 

2 6 



18 70 

22 65 

25 87 

7 15 

16 50 



104 
17 



Percentage 
of Deaths. 



Total 
Cases. 



Col- 
lapse 
Cases. 



49.4 
46.0 
35.8 
52.5 
50.5 



48.1 
40.7 
27.3 
61.7 
30.5 
46.1 
26.3 



61.4 
42.2 
63.0 
48.3 
45.0 



698 

80.9 



75.7 
59.8 
57.2 
71.1 
67.1 



76.5 
52.3 
67.0 
76.9 
73.3 
85.7 
55.5 



77.7 
89.0 
80.5 
65.2 
62.0 



77.6 

80.9 



General Board of Health. Keport on the Results of the- 
Different Methods of Treatment pursued in Epidemic Cholera, 
in the Provinces throughout England and Scotland in 1854 ; 
being Supplemental to the Metropolitan Report, addressed to 
the President of the General Board of Health. By the Treat* 
ment- Committee of the Medical Council, 1855. P. 24. — 
(Medical Times and Gazette, October 27th, 1855.) 



